LIBRARY OF CONGRESS, 

T^TB 

SiielffJTS. 



n. 



■rt 



UNITED STATES OF AMERICA. 



A MANUAL 



AUSCULTATION AND PERCUSSION, 



EMBRACING THE 



PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS AND 
HEART, AND OF THORACIC ANEURISM. 



BY 

AUSTIN FLINT, M.D., LL.D., 

PROFESSOR OF TUB PRINCIPLES AND PRACTICE OP MEDICINE AND OF CLINICAL MEDICINE IN THE 
BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC., ETC. 



FOURTH EDITION, THOROUGHLY REVISED AND ENLARGED. 



ILLUSTRATED WITH FOURTEEN WOODCUTS. 




PHILADELPHIA : 

LEA BROTHERS & CO 

188 5. 



V^cn 



3 



Entered according to Act of f'oiigress, in tlie year 1?8.% liy 

LEA BROTHERS k CO., 

In the Office of tlie Librarian of Conoress, at WashinRtoii, P. C. All rights reserved. 



DORNAN, PRINTP:R. 



O'J 



PREFACE TO THE FOURTH EDITION. 



The fact that, within a little over two years, a 
large edition of this manual has been exhausted, is 
gratifying proof of the increased favor with which 
it is regarded by the medical profession. The 
Author has been thereby incited to endeavor to 
make it still more acceptable by a thorough revision. 

The present edition contains some important 
modifications and considerable additions. A notable 
improvement is the introduction of diagrammatic 
illustrations, which will enhance the usefulness of 
the work. 

New York, October, 1885. 



Figs. 1, 2, 3, and 4 are borrowed, with modifica- 
tions, from Handbuch und Atlas der topographischen 
percussion, von Dr. Adolf Weil, Professor an der 
Universitat Heidelberg. 



PREFACE TO THE THIRD EDITION. 



In the revision of this manual for a third edition, 
it has been deemed advisable, as in the previous 
editions, to restrict its scope to- auscultation and 
percussion considered chiefly with reference to their 
practical application, and to present these with as 
much condensation as possible. In the present 
edition, the modes by which pulmonary signs may 
be reproduced in the lungs removed from the body, 
and by artificial illustrations, have been briefly stated. 
The author has also introduced some practical points 
kindly suggested by his friend and colleague. Pro- 
fessor Janeway. The speedy exhaustion of the 
second edition may, perhaps, be fairly regarded as 
evidence, not alone of the usefulness of the work to 
the medical student and practitioner, but of an 
increasing appreciation of the importance of the 
study of auscultation and percussion, as well as of 
the analytical method by which the study is facili- 
tated, and knowledge of the physical signs made 
readily available in diagnosis. 

New York, March, 1883. 



PREFACE TO THE SECOND EDITION. 



This work contains the substance of the lessons 
which the Xuthor has for many years given, in con- 
nection with practical instruction in auscultation 
and percussion, to private classes composed of 
medical students and practitioners. 

In his courses of practical instruction his plan has 
been, 1st. To simplify the subject as much as pos- 
sible, avoiding all needless refinements ; 2d. To 
consider the distinctive characters of the different 
physical signs as determined, not by analogies, nor 
by deductions from physics, but by analysis, and as 
based especially on variations in the intensity, pitch, 
and quality of sounds ; 3d. To impress the fact that 
the significance of physical signs relates to certain 
physical conditions, and the importance of a familiar 
acquaintance with these conditions, as well as with 
the distinctive characters of the signs by which they 
are represented ; 4th. To enforce the necessity of 
sufficient study of the physical conditions and the 
signs of health, as a sine qua non for success in the 
study of the physical diagnosis of diseases ; and, 5th. 
To waive discussion of the mechanism of signs. 



Vlll PREFACE TO THE SECOND EDITION. 

whenever this is open for discussion, taking the 
ground that our knowledge of the significance of 
signs rests solely on the constancy of their connection 
with the physical conditions which they represent. 

This plan, of which the utility has been confirmed 
by continued experience, has been followed through- 
out the present volume, and the favor with which 
the work has been received has seemed .to show that 
no radical changes were required. In revising it 
for a second edition, therefore, the Author has con- 
fined himself to such additions as seemed likely to 
render it more useful tiot only to students engaged 
in the practical study of the subject, but also to 
practitioners as a handbook for ready reference. 

New York, January, 1880. 



CONTENTS. 



CHAPTEK I. 

INTRODUCTION. 

Definition of percussion and auscultation — The sounds obtained by 
these methods of representing healthy and morbid physical con- 
ditions — Definition of signs — The basis of our knowledge of signs 
the constancy of association of certain sounds with certain phy- 
sical conditions in health and disease — The present state of per- 
fection of our knowledge of signs furnished by auscultation and 
percussion — Requirements for the successful study of these 
methods of exploration — The anatomy and physiology of the 
chest — An enumeration of the points relating thereto which are 
of especial importance — The physical conditions incident to the 
different diseases of the chest: the conditions relating to the 
respiratory system stated, and a summary of them — The dis- 
tinctive characters of healthy and morbid signs ; variations in 
intensity, pitch, and quality, considered as the chief source of 
the characters distinguishing the signs of disease from each other 
and from those of health — Other distinctions than those of inten- 
sity, pitch, and quality — The analytical method of the study of 
auscultation and percussion— The significance of signs as regards 
the physical conditions which they severally represent — Morbid 
conditions, not individual diseases, represented by the morbid 
signs — Regional divisions of the chest — Anatomical relations of 
the regions severally to the parts within the chest, 

CHAPTEK II. 

PERCUSSION IN HEALTH. 

Percussion with the fingers or with a percussor and pleximeter — 
The normal vesicular resonance on percussion; its distinctive 
characters relating to intensity, pitch, and quality — Variations 
in the characters of the normal vesicular resonance in different 



CONTENTS. 



persons — Relation of the pitch of resonance to the vesicular 
quality — Tympanitic resonance over the abdomen — Variations 
of the normal resonance in the different regions of the chest- 
Enumeration of the regions in which the resonance on the two 
sides varies, and those in which it is identical in health — In- 
fluence of age on the normal resonance — Influence of the acts 
of respiration on the resonance — Rules in the practice of per- 
cussion, ............ 



CHAPTEK III. 

PEECUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion — 
Requirements for a practical knowledge of these signs — The 
distinctive characters of the morbid physical conditions repre- 
sented by, and the different diseases into the diagnosis of which 
enter, the signs, severally, to wit, 1. Absence of resonance or 
flatness; 2. Diminished resonance; 3. Tympanitic resonance; 
4. Vesiculo-tympanitic resonance; 5. Amphoric resonance; 6. 
Cracked-metal resonance — Sense of resistance felt in the practice 
of percussion, as a morbid sign, ....... 

CHAPTEK IV. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — Im- 
mediate and mediate auscultation— Advantages of the binaural 
stethoscope — Rules to be observed in auscultation — Divisions of 
the study of auscultation in health— The normal laryngeal and 
tracheal respiration — The normal vesicular murmur; its distinc- 
tive characters, and the variations in the different regions on the 
same side, and in corresponding regions on the two sides of the 
chest — The normal vocal resonance — The laryngeal and tracheal 
voice and whisper — The normal thoracic vocal resonance and fre- 
mitus ; the distinctive characters of each: the variations in dif- 
ferent regions on the same side, and in corresponding regions on 
the two sides of the chest — The normal bronchial whisper, with 
its variations in different regions on the same side, and in corre- 
sponding regions on the two sides of the chest, .... 



CONTENTS. 



CHAPTER V. 



AUSCULTATION IN DISEASE. 



The respiratory signs of disease: — Abnormal modifications of the 
normal respiratory sounds: — Increased vesicular murmur — Di- 
minished vesicular murmur — Suppressed respiratory sound — 
Bronchial or tubular respiration — Broncho-vesicular respiration 
— Cavernous respiration^Broncho-cavernous respiration — Vesic- 
ulo-cavernous respiration — Amphoric respiration — Shortened in- 
spiration — Prolonged expiration — Interrupted respiration. Ad- 
ventitious respiratory sounds or rales. Laryngeal or tracheal 
rales — Moist bronchial rales, coarse, fine, and subcrepitant — 
Vesicular or crepitant rale — Cavernous or gurgling rale — Pleural 
friction rales, metallic tinkling and splashing — Indeterminate 
rales. The vocal signs of disease: Bronchophony — AVhispering 
bronchophony — jEgophony — Increased vocal resonance — In- 
creased bronchial whisper — Cavernous whisper — Pectoriloquy — 
Amphoric voice or echo — Diminished and suppressed vocal reso- 
nance — Diminished and suppressed vocal fremitus — Metallic 
tinkling. Signs obtained by acts of coughing or tussive sounds, . 



CHAPTER VI. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE RESPIRATORY 
ORGANS. 

Affections of the larynx and trachea — Bronchitis seated in large 
bronchial tubes — Bronchitis seated in small bronchial tubes, or 
capillary bronchitis — Collapse of pulmonary lobules — Lobular 
pneumonia — Asthma — Pulmonary or vesicular emphysema — 
Pleurisy, acute and chronic — Empyema— -Hydrothorax — Pneu- 
mothorax — Pneumohydrothorax — Pneumo-pyothorax — Acute v 
lobar pneumonia — Circumscribed pneumonia — Embolic pneu- 
monia — Hemorrhagic infarctus — Pulmonary apoplexy — Pulmo- 
nary gangrene — Pulmonary oedema — Carcinoma of lung — Tumor 
vpithinthe chest — Acute miliary tuberculosis — Pulmonary phthisis 
— Fibroid phthisis, interstitial pneumonia, or cirrhosis of lung- 
Diaphragmatic hernia, , . . . . . . . .154 



CONTENTS 



CHAPTEK VII. 

THE PHYSICAL CONDITIONS OF THE HEART IN HEALTH AND 
DISEASE. THE HEART-SOUNDS AND CARDIAC MURMURS. 

PAG 

Physical conditions of tlie heart in health: Boundaries of the 
prajcordia — Normal situation of the apex-beat — Boundaries of 
the deep and of the superficial cardiac space — Relations of the 
aorta and the pulmonary artery to the walls of the chest — -The 
heart-sounds — Characters distinguishing the first and the second 
sound — Mechanism of the production of the heart-sounds — Aus- 
cultation of the pulmonic and the aortic second sound separately 
— Auscultation of the mitral and tricuspid valvular sounds — 
Movements of the auricles and ventricles in relation to each 
other — Physical conditions of the heart in disease : Enlarge- 
ment of the heart — Hypertrophy and dilatation — Abnormal im- 
pulses of the heart, and modifications of the apex-beat — Valvular 
lesions — Roughness of the pericardial surfaces — Liquid within 
the pericardial sac — Abnormal modifications of the heart-sounds 
— Reduplication of heart-sounds — Cardiac murmurs — Normal and 
abnormal blood-currents within the heart, and their relations 
with the heart-sounds — Mitral direct murmur — Mitral regurgi- 
tant murmur — Mitral systolic non-regurgitant, or intra-ventric- 
ular murmur — Mitral diastolic murmur — Aortic direct murmur — 
Aortic regurgitant murmur, and an Aortic diastolic non-regurgi- 
tant niurmur — Coexisting endocardial murmurs — Tricuspid direct 
murmur — Tricuspid regurgitant murmur — Pulmonic direct 
murmur — Pulmonic regurgitant murmur — Facts of practical im- 
portance in relation to endocardial murmurs— Pericardial or fric- 
tion mvirmur, ........... 20 



CHAPTER VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE HEART AND OF 
THORACIC ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — Valvular 
lesions, mitral, aortic, tricuspid, and pulmonic— Fatty degenera- 
tion and softening of the heart — Endocarditis — Pericarditis — 
Functional disorders — Thoracic aneurism 250 



MANUAL 

OF 

AUSCULTATION AND PERCUSSION. 



CHAPTER I. 

INTKODUCTION. 

Definition of percussion and auscultation — The sounds obtained by these 
methods of representing healthy and morbid physical conditions — 
Definition of signs — The basis of our knowledge of signs the constancy 
of association of certain sounds with certain physical conditions in 
health and disease — The present state of perfection of our knowledge 
of signs furnished by auscultation and percussion — Requirements for 
the successful study of these methods of exploration — The anatomy 
and physiology of the chest — An enumeration of the points relating 
thereto which are of especial importance — The physical conditions in- 
cident to the different diseases of the chest: the conditions relating 
to the respiratory system stated, and a summary of them — The dis- 
tinctive characters of healthy and morbid signs; variations in inten- 
sity, pitch, and quality, considered as the chief source of the character 
distinguishing the signs of disease from each other and from those of 
health — Other distinctions than those of intensity, pitch, and quality — 
The analytical method of the study of auscultation and percussion — 
The significance of signs as regards the physical conditions which they 
severally represent — Morbid conditions, not individual diseases, repre- 
sented by the morbid signs — Regional divisions of the chest — Ana- 
tomical relations of the regions severally to the. parts within the chest. 

Physical Exploration. 

The physical exploration of the chest embraces six 
clifierent methods, namely : auscultation, percussion, 
inspection, palpation, mensuration, and succussion. 
Of these, auscultation and percussion, dealing with 



14 INTRODUCTION. 

sounds, involve the sense of hearing. In percussion, 
the sounds are produced by striking upon the walls 
of the chest; in auscultation, they are caused by 
acts of breathing, speaking, and coughing. 

The sounds in auscultation and percussion are, 
1st, normal or healthy sounds, being produced 
when there is no disease of the chest; and, 2d, ab- 
normal or morbid sounds, being produced when the 
chest is the seat of disease. The sounds, healthy 
and morbid, constitute what are known as physical 
signs. Frequently, for the sake of brevity, the term 
signs, without the word physical, is used to denote 
these sounds. Conventionally, physical signs, or 
signs, are terms employed in a sense of contradis- 
tinction to the term symptoms. The signs are dis- 
tinguished, of course, as normal or healthy, and 
abnormal or morbid. 

The sounds which constitute signs represent cer- 
tain physical conditions pertaining to the chest. 
The normal or healthy signs represent physical con- 
ditions existing when the organs are not affected by 
disease ; the abnormal or morbid signs represent 
physical conditions which are deviations from those 
of health, being incident to the various diseases of 
the chest. The physical conditions represented by 
signs may be distinguished as normal or healthy, 
and abnormal or morbid conditions. 

The representation of healthy and morbid physical 
conditions by certain healthy and morbid signs is 
established by having ascertained a constancy of 
association of the signs with the conditions. This 
constancy of association is ascertained by observa- 
tion or experience. The sounds obtained by per- 



PHYSICAL EXPLORATION. 15 

cussion and auscultation in health are thereby 
established signs of healthy conditions, and the 
sounds obtained only in cases of disease are thereby 
established signs of morbid conditions. Our knowl- 
edge of certain sounds as the signs of certain phy- 
sical conditions can have no reliable basis other 
than the constancy of the connection of the former 
with the latter. This constancy of connection is 
determined by the study of the sounds during life 
and examination of the organs after death. The 
existence of certain conditions is not to be inferred 
from the characters of certain sounds until the con- 
nection of the sounds with the conditions has been 
ascertained by experience ; then, and then only, are 
the sounds to be reckoned as signs of these condi- 
tions. So, also, it is not to be inferred from certain 
physical conditions found after death, that certain 
sounds must have been produced during life, until 
the connection between the conditions and the 
sounds has been ascertained by experience. In 
other words, our knowledge of signs as represent- 
ing physical conditions, can rest on no other than a 
purely empirical foundation. 

Our knowledge of the signs representing the phy- 
sical conditions in health and disease, thanks to the 
labors of Laennec, and of those who have followed 
in his footsteps, has been brought to great perfec- 
tion. The practical object of this knowledge is to 
determine by means of auscultation and percussion, 
together with the other methods of exploration, the 
existence of either healthy or morbid physical condi- 
tions, and to discriminate the latter from each other; 
that is to say, the practical object is diagnosis. The 



16 INTRODUCTION. 

signs now known to represent physical conditions, 
healthy and morbid, taken in connection with symp- 
toms and pathological laws, render, for the most part, 
the diagnosis of diseases of the chest easy and posi- 
tive. Hence, it becomes the duty of the medical 
student and practitioner to give to auscultation and 
percussion attention sufficient, at least, for their 
practical application to the diagnosis of the diseases 
commonly met with in medical practice; and this 
duty is the more imperative because it involves 
neither peculiar difficulties nor great labor. In 
entering upon the undertaking it is important to 
consider the requirements for the successful study 
of this province of practical medicine. These 
requirements relate to : 1st, the anatomy and phy- 
siology of the chest ; 2d, the morbid physical con- 
ditions incident to the different diseases of the chest; 
3d, the distinctive character of healthy and morbid 
signs; and, 4th, the significance of the signs as re- 
gards the physical conditions which they severally 
represent. 

Anatomy and Physiology of the Respiratory Organs. 

The necessity of a knowledge of the anatomy and 
physiology of the chest, as a requirement for the 
study of auscultation and percussion, together with 
the other methods of physical exploration, is too 
obvious to need any discussion. The physical con- 
ditions of health must be known as preparatory for 
appreciating the physical conditions of disease. It 
would be absurd to think of studying the latter until 
the former are known. The student, therefore, who 
is not acquainted with the anatomy and physiology 



ANATOMY AND PHYSIOLOGY OF CHEST. 17 

of the chest, must defer entering upon the study of 
physical diagnosis until this requirement is fulfilled. 
Familiarity with the morbid physical conditions is 
necessary ; and for the advanced medical student or 
the practitioner it is advisable to refresh the memory 
with a reviewal of certain anatomical and physio- 
logical points before beginning the study of auscul- 
tation and percussion. These points, relating espe- 
cially to the physical conditions of health, cannot be 
considered in this work. A simple enumeration of 
them can only be introduced, the reader being re- 
ferred for details to treatises on anatomy and phj^- 
siology. 

Important anatomical conditions relate to the 
bones of the chest, namely, the general conforma- 
tion of the thorax ; the differences in respect of the 
obliquity of the ribs from above downward; the 
direction of the costal cartilages, their connection 
with the sternum, and the angles formed by the 
junction of the ribs and cartilages ; the differences 
in width of the intercostal spaces in the upper, 
middle, and lower portions of the anterior, lateral, 
and posterior aspects of the thorax, together with 
the relations of the scapula and clavicle. The rela- 
tive thickness of the muscular covering of the chest 
in different situations is to he considered, and, in 
women, the varying size of the mammse. The at- 
tachments of the diaphragm to the thoracic walls, 
and its relations to the organs below, as well as 
above it, are points of importance. Figs. 1, 2, 3, 4. 
Important physiological conditions relate to the 
parts which the ribs, costal cartilages, sternum, and 
diaphragm severally play in the movements of respi 
2* 



18 INTRODUCTION. 

ration. The differences, in respect of these move- 
ments, in tranquil and in forced breathing. The 
contrast between the two sexes, and between early 
and advanced life, are points to be studied. Other 
points are, the frequency of the respirations in 
health, and the relative duration, rapidity, and 
force of the inspiratory and the expiratory move- 
ments. 

Certain anatomical and physiological points per- 
tain to the organs within the chest. The more 
important of these, relating to normal physical con- 
ditions, are the following: 1st, as regards the lungs, 
the connections of the pleura, and the smoothness 
of the pleural surfaces in contact with each other; 
the relations of the apex and base of each lung to 
the chest-walls, and the differences of the two lungs 
in this respect; the relative spaces occupied respec- 
tively by the two lobes of the left, and the three 
lobes of the right lung ; the situation of the inter- 
lobar fissures in either side on the posterior, lateral, 
and anterior aspects of the chest ; the arrangement 
of the air-vesicles, pulmonary lobules, and the dif- 
ferent-sized intra-pulmonary bronchial tubes; the 
expansion of the air-vesicles, and the movement of 
the current of air from larger to smaller bronchial 
tubes in the act of inspiration, the vesicles diminish- 
ing in size, and the current of air moving from 
smaller to larger tubes in the act of expiration; the 
difference in respect of the relative proportion of air 
and solids at the end of inspiration and at the end 
of expiration; the extent to which the volume of 
the lungs may be diminished by a forced act of ex- 
piration, and increased by a forced act of inspira- 



ANATOMY AND PHYSIOLOGY OF CHEST. 10 

tion; the relations of the apices to the subclavian 
arteries, and the variable extent to v^hich the apex 
rises on either side above the clavicle. 2d, as re- 
gards the larynx, trachea, and the bronchial tubes 
without the lungs, the anatomy and physiology of 
the vocal chords, of the muscles concerned in the 
movements of respiration and of phonation, with 
the relations of each to the recurrent laryngeal 
nerve, the size of the rima glottidis in youth, after 
puberty, and relatively in the two sexes, the enlarge- 
ment of the. rima in the act of inspiration, the dimi- 
nution of its size in the act of expiration, and the 
closer approximation of the chords in the act of 
coughing ; the difference in the amount of areolar 
tissue above the vocal chords in children and in 
adults ; the situation of the trachea, and the point 
of its bifurcation; the length, direction, and size of 
the two primary bronchi contrasted with each other, 
and the branches which penetrate the lungs, 3d, as 
regards the heart, the boundaries of the space which 
it occupies — that is, of the prsecordial space ; the 
relation of the aorta and pulmonic artery to the 
walls of the chest; the portions of the prsecordial 
space in which the heart is covered and uncovered 
by lung; the situations of the auricles and ven- 
tricles respectively; the relations of these to each 
other, and the arrangements of the valves; the 
currents of blood through the orifices within the 
heart, and the relations of each of these to the heart- 
sounds ; the rhythmical succession of these sounds ; 
the differences which distinguish each from the other 
in respect of loudness, duration, tone, quality, extent 
of diffusion, and the situation in which each has its 



20 INTRODUCTION. 

maximum of intensity ; the mechanism of these 
sounds, and the situation of the apex-beat. Figs. 1, 
2, 3, 4. 

The foregoing are the anatomical and phj^sio- 
logical points which especially claim attention with 
reference to normal physical conditions, preparatory 
to entering on the study of abnormal physical con- 
ditions represented by the signs furnished by auscul- 
tation and percussion together with the other methods 
of physical exploration. 

It is recommended to the student, before pro- 
ceeding further, either to acquire or review knowl- 
edge respecting all these points. Knowledge of 
these should be made familiar, if it be not already 
so, by reference to works treating of the anatomy 
and physiology of the chest. 

The Morbid Physical Conditions Incident to the Different 
Diseases of the Respiratory System. 

The various morbid physical conditions incident 
to different diseases must be known, for it is the 
immediate object of auscultation, percussion, and 
the other methods of exploration, to ascertain either 
the existence or the absence of these morbid con- 
ditions. Knowledge of all the important conditions 
which are deviations from those of health, and the 
relations of each to different diseases, is, therefore, 
an essential requirement. 

Deviations from the normal conformation of the 
chest and the various abnormal movements of respi- 
ration, belong properly among the physical signs 
obtained by inspection, palpation, and mensuration. 
For the most part, these signs represent morbid 



DISEASES OF EESPIRATORY SYSTEM. 21 

physical conditions within the chest. Certain con- 
ditions relate to the presence of liquid, either serous, 
sero-fibrinous, or purulent, within the pleural sac. 
The quantity of liquid may be large enough to com- 
press the lung into a solid mass, and to enlarge the 
affected side, at the same time restraining or annul- 
ling the respiratory movements ; the chest on the 
affected side, then, will contain only lung solidified 
by compression, and liquid. In other cases the 
quantity of liquid is either small, moderate, or con- 
siderable, the lung then containing a lessened 
quantity of air, and its volume diminished in pro- 
portion to the amount of liquid. These morbid 
conditions are incident to simple pleurisy with 
effusion, pyothorax or empyema, and hydrothorax. 

The pleural surfaces, in cases of pleurisy, may be 
more or less covered with recent fibrinous exuda- 
tion, and, when not separated by the presence of 
liquid, they do not move upon each 'other smoothly 
and noiselessly. The friction of the opposed sur- 
faces is still more productive of audible and some- 
times tactile signs after the absorption of liquid, 
when the exudation has become more adherent and 
dense than when it is recent. 

The presence of air in the pleural space, either 
alone or with more or less liquid, in pneumothorax, 
may compress the lung into a solid mass, also dilat- 
ing the affected side, and restraining or annulling 
its movements ; and the air, with or without liquid, 
when not in sufficient quantity to produce these 
effects, may diminish more or less the volume of the 
lung and the amount of air in the pulmonary vesicles. 
These morbid conditions give rise to characteristic 



22 INTRODUCTION. 

physical signs. The perforation of lung, usually 
existing in cases of pneumothorax, occasions addi- 
tional signs which are characteristic. 

Solidification of lung is an important physical 
condition incident to several diseases, irrespective 
of the condensation, just referrred to, caused by the 
compression of liquid or air in the pleural sac. 
Complete consolidation of an entire lobe, or of two 
and even three lobes, exists in the second stage of 
lobar pneumonia. Certain physical signs represent 
this condition of complete solidification. The dif- 
ferent degrees of solidification, namely, slight, mod- 
erate, and considerable, occur during the stage of 
resolution in cases of pneumonia, and these gra- 
dations are severally represented by well-defined 
characters pertaining to physical signs. Solidifica- 
tion, circumscribed, forming nodules which vary in 
size and number, situated in the upper, lower, or 
middle portion of the lung, either on one side or on 
both sides, exists in phthisis, in broncho-pneumonia 
and collapse of pulmonary lobules, in hydatids, in 
hemorrhagic infarctus and embolic pneumonia, in 
pulmonary gangrene, and in carcinoma. It exists, 
greater or less in degree and more or less extended, 
in interstitial pneumonia. In these dififerent con- 
nections the existence of solidification, its degree 
and extent, its limitation to one situation or its ex- 
istence at ditferent points, are determinable by means 
of physical signs. 

A morbid condition the opposite of solidification 
is an abnormal accumulation of air within the air- 
vesicles of the lungs. This is incident to pulmonary 
or vesicular emphysema, involving a morbicl dilata- 



DISEASES OF RESPIRATORY SYSTEM. 23 

tion of the air-vesicles. The permanent expansion 
and increased volume of the upper lobes in some 
cases -of this disease, occasion a characteristic de- 
formity of the chest, together with certain devia- 
tions from the normal movements of respiration, 
which are also characteristic. This morbid condi- 
tion is represented by distinctive signs furnished by 
auscultation and percussion. The extravasation of 
air in the connective tissue, constituting interlobular 
and subpleural emphysema, in like manner gives rise 
to signs furnished by these methods of exploration. 

The presence of a viscid exudation within the air- 
vesicles and bronchioles, is a morbid physical condi- 
tion incident to acute pneumonia, especially in its 
first stage, agglutinating the cells and bronchioles, 
the walls of which may be brought into contact or 
close proximity at the end of the act of expiration. 
The separation of the walls thus agglutinated, in 
the act of inspiration, gives rise to an auscultatory 
sign (the crepitant rS,le) which is pathognomonic of 
that disease. 

An accumulation of serum within the air-vesicles 
constitutes the condition called pulmonary oedema. 
This condition gives rise to signs furnished by aus- 
cultation and percussion. 

Liquid within the bronchial tubes (serum, pus, 
blood, or thin mucus) is a condition incident to pul- 
monary cedema, abscess either of the lung or situated 
elsewhere and evacuating through the bronchial 
tubes, phthisis, bronchorrhagia, pneumorrhagia, 
bronchorrhcea, and bronchitis. The passage of air 
through the different varieties of liquid in the tubes 
causes bubbling sounds which are appreciable in 



24 INTRODUCTION". 

auscultation. The apparent size of the bubbles 
(coarseness or fineness) denotes the size of the tubes 
in which they are produced, and the pitch of the 
bubbling sounds denotes either solidification or 
otherwise of the pulmonary substance surrounding 
the tubes in which the bubbles are produced. Bub- 
bling sounds more intense and on a larger scale are 
caused by the presence of liquid within the trachea 
and larj^nx, known as the tracheal r^les or the death 
rattle. 

Diminished calibre of the bronchial tubes within 
the lungs, either localized or diffused, is a condition 
due. to the presence of tenacious naucus, and the 
swelling of the mucous membrane in cases of bron- 
chitis. In cases of so-called capillary bronchitis 
the condition may involve an alarming degree of 
obstruction. The same morbid condition is inci- 
dent to bronchial spasm in asthma, occasioning in 
this disease great suffering, but without immediate 
danger. The condition is represented by ausculta- 
tory signs which enable the auscultator to differ- 
entiate the obstruction due to capillary bronchitis 
from that due to bronchial spasm. Permanent ob- 
literation of more or less of the bronchial tubes is 
an occasional morbid condition. 

Obstruction of a bronchial tube, either within or 
without the lung, is a morbid condition involving 
the loss of respiratory sound within the area of the 
bronchial branches and vesicles not receiving air in 
consequence of the obstruction. The obstruction 
may be temporary, being caused by a plug of mucus 
of suflicient size to prevent the passage of air ; the 
morbid condition is then incident to bronchitis. 



DISEASES OF RESPIRATORY SYSTEM. 25 

One of the primary bronchi may be obstructed 
temporarily by a plug of mucus, and obstruction of 
the larynx in childhood thus produced may be suffi- 
cient to cause death by sutFocation, The inhalation 
of foreign bodies is another cause of obstruction 
within the larynx, trachea, or bronchi. A primary 
bronchus or the trachea may be pressed upon by an 
aneurismal or other tumor, and, in this way, more 
or less obstruction to the passage of air is produced. 
However produced, the situation of the obstruction 
and its degree are, in general, determinable by 
means of auscultatory signs. 

Dilatation of bronchial tubes occasions two morbid 
physical conditions differing as regards their auscul- 
tatory signs, namelj^, 1st, an enlargement of greater 
or less extent, the tubes preserving their cylindrical 
form; and, 2d, a sacculated enlargement. The 
former occurs generally in connection with solidifi- 
cation around the tubes from hyperplasia of the 
areolar tissue, and is thus incident to interstitial 
pneumonia. The latter may give rise to signs 
which represent pulmonary cavities. 

Sacculated dilatations of bronchial tubes, and the 
cavities incident to phthisis, pulmonary abscess and 
circumscribed gangrene of lung, are represented by 
well-marked and highly distinctive signs furnished 
by auscultation and percussion. The signs denote 
either that cavities have flaccid walls which collapse 
in expiration and expand in inspiration, or that, 
owing to solidification of lung, they remain open 
during both acts of respiration. 

More or less of the space within the chest which, 
normally, is occupied by lung, may be encroached 



26 INTRODUCTION. 

upon by aneurisms or other intra-thoracic tumors. 
This is a physical condition giving rise to notable 
morbid signs furnished by auscultation and per- 
cussion. 

Finally, an extremely rare morbid physical con- 
dition is the presence of more or less of the hollow- 
viscera of the abdomen within the chest, in conse- 
quence of either a congenital deficiency in the 
diaphragm, or a wound penetrating this muscle 
(diaphragmatic hernia). 

The foregoing morbid physical conditions relate 
to the respiratory organs. Those relating to the 
heart are deferred in order that they may precede 
more immediately an account of the signs of cardiac 
disease. As a requirement for the study of morbid 
physical signs, the foregoing morbid physical condi- 
tions must be understood and memorized. To 
assist the student in the latter, a summary of these 
conditions is appended. 

Summary of Morbid Physical Conditions Incident to 
Diseases of the Respiratory Organs. 

1. An accumulation of serous, sero-fibrinous, or 
purulent liquid sufficient to fill the affected side of 
the chest, and sometimes causing more or less en- 
largement. 

2. An accumulation of liquid partially filling the 
affected side of the chest, the quantity being either 
small, moderate, or considerable. 

3. Fibrinous exudation on the pleural surface. 

4. Air with liquid within the pleural cavity, and 
perforation of lung. 



HEALTHY AND MOEBID SIGNS. 27 

5. Air without liquid in tlie pleural cavity. 

6. Solidification of lung, either complete or ap- 
proximating to completeness. 

7. Solidification of lung, slight or moderate in 
degree. 

8. Dilatation of the air-vesicles, involving within 
them an abnormal accumulation of air. 

9. Extravasation of air within the pulmonary 
connective structure. 

10. Exudation within air-vesicles and bronchioles. 

11. Liquid within air-vesicles. 

12. Liquid (mucus, serum, pus, or blood) within 
bronchial tubes of large, medium, or small size. 

13. Liquid within bronchial tubes of minute size. 

14. Obstruction of the pulmonary bronchial tubes 
by mucus, swelling of the mucous membrane, and 
spasm of the bronchial muscular fibres. 

15. Obstruction of larynx, trachea, or bronchi 
exterior to the lungs, by plugs of mucus or foreign 
bodies. 

16. Obstruction of the trachea or a primary bron- 
chus by aneurismal or other tumors. 

17. Dilatation of bronchial tubes, cylindrical or 
sacculated. 

18. Pulmonary cavities. 

19. Tumor within the chest. 

20. Diaphragmatic hernia. 

The Distinctive Characters of Healthy and Morbid Signs. 

Eor the practice of auscultation and percussion it 
is essential to be able to recognize the signs, sever- 
ally, which represent the different physical condi- 
tions in health and disease. It is essential to dis- 



28 INTRODUCTION. 

tiuguish the morbid from the healthy signs, and to 
discriminate from each other, severally, the signs 
of disease. The recognition and discrimination 
of signs require a knowledge of the distinctive 
characters belonging to each of them. In entering 
upon the study of the signs, therefore, it is a neces- 
sary requirement to know whence their distinctive 
characters are derived. To this point of inquiry the 
attention of the student is now invited. 

The signs being sounds, they are to be recognized 
and discriminated in the way in which we practically 
recognize and discriminate other sounds. It is not 
necessary, in order to do this, to study the science 
of acoustics. In becoming familiar with other 
sounds, for example, musical notes produced by 
different instruments, or the varieties of the human 
voice, we do not have recourse to that science. It 
suffices for all practical purposes to contrast the 
sounds obtained by auscultation and percussion with 
reference to very simple and obvious differences ; 
and, yet, it is necessary to understand very clearly 
in what these differences consist, or, in other words, 
the sources of the distinctive characters of these 
sounds. The more important of the differences be- 
tween the sounds obtained by auscultation and per- 
cussion relate to intensity, pitch, and quality. The 
distinctive characters of most of the signs are derived 
from these three sources. In becoming practically 
acquainted with the signs, they are to be contrasted 
as regards intensity, pitch, and quality, precisely as 
we would bring other sounds into contrast in these 
three aspects. The distinctive characters of the 
signs, severally, are especially derived from their 



HEALTHY AND MORBID SIGNS. 29 

differences in these respects. The distinctions ex- 
pi-essed by the terms intensity, pitch, and quality, 
are, therefore, to be made clear. 

Differences in the intensity of sounds are easily 
understood. One sound is more intense than another 
sound when it is simply louder, and varying degrees 
of intensity are expressed by such terms as feeble or 
weak and loud, to which may be prefixed adjectives 
of quantity, such as very, moderate, etc. This is all 
that need be said with reference to the first of the 
three aspects under which sounds are contrasted. 
It will be seen hereafter that intensity is an essential 
element in the distinctive characters of certain of 
the signs. 

r Differences in the pitch of sounds are easily un- 
derstood by those who have given any attention to 
music. The differences are expressed by the terms 
high and low, to which may be prefixed words de- 
noting a greater or less degree of highness or low- 
ness. A nice appreciation of variations in the pitch 
of musical notes, requires what is known as a " mu- 
sical ear;" but a very nice appreciation is not 
essential in comparing, as regards pitch, the sounds 
studied in auscultation and percussion. For the 
most part, these sounds are not musical notes ; 
nevertheless, differences in pitch are readily per- 
ceived. A musical ear is undoubtedly an advantage 
in readily distinguishing differences in pitch ; but it 
is by no means a sine qua non. For those who have 
given no attention to music, some difficulty may be 
at first experienced in judging correctly of differ- 
ences in this regard; but the difficulty disappears 
after a little practice. Differences in pitch now 

3* 



30 INTRODUCTION. 

enter pretty largely into the distinctive characters 
of physical signs; but by Laennec, and those who im- 
mediately followed him, comparatively little atten- 
tion was paid to the study of signs with reference to 
these differences. The writer was led to engage in 
this study more than a quarter of a century ago, 
and hereafter, in giving an account of the different 
signs, he will claim to have been the first to have 
clearly indicated certain characters from this source.^ 
Differences relating to quality are apt, at first, to 
be confounded with those relating to pitch ; hence 
the distinction between pitch and quality must be 
clearly understood. We may say of the quality of 
a sound, that it embraces whatever is not embraced 
in the terms intensity and pitch. This is true as a 
general statement. The sense of the term quality, 
in distinction from intensity and pitch, may be most 
readily made clear by an illustration. Let it be sup- 
posed that we hear the notes of an instrument which 
is unseen — the performer, for example, being in an- 
other room. We recognize at once the instrument 
by the notes, provided it be one with which we are 
familiar, such as a violin, a fiute, a clarionet, etc. 
We do not need to see the instrument; we recognize 
it by the sounds. ISTow, how do w^e recognize it ? 
Certainly not by the intensity of the sounds; it 
matters not whether these be loud or weak, so that 
we hear them. Certainly not by the pitch ; for if a 
piece of music be performed, we get both high and low 
notes. We recognize the instrument by the quality 

1 Vide Prize Essay on " Variations of Pitch in Percussion and 
Eespiratory Sounds, and tlieir Application to Physical Diagnosis." 
Transactions of the American Medical Association, 1852. 



HEALTHY AND MORBID SIGNS. 31 

of the sounds. Each musical instrument, owing 
to its peculiarity of construction, yields sounds 
which are peculiar to it ; and after we have become 
familiar with the quality of sounds peculiar to an 
instrument, we immediately thereby recognize it. 
Precisely in the same way we may recognize certain 
sounds produced by auscultation and percussion in 
health and disease. The signs differ in quality ac- 
cording to the physical conditions which they sever- 
ally represent; and differences in quality will be 
found hereafter to constitute essential and obvious 
distinctions by which the signs of health and disease 
are recognized and discriminated. This is a source 
of some of the most distinctive of the characters of 
certain of the physical signs. 

Of the peculiar quality of any particular sound 
one can form no definite idea otherwise than by 
direct observation. That is to say, no one could 
describe to another the peculiar quality of a par- 
ticular sound so that it would be clearly appre- 
hended without the sound having been heard. 
Imagine the attempt to describe the sound of a 
violin to a person who had never listened to the 
notes from that instrument — it would be impossible 
to give a correct idea of it in language. The only 
way in which an approximate idea could be con- 
veyed in words, would be by comparing the quality 
to that of some other instrument to the notes of 
which there was some resemblance — that is, by 
analogy. To attempt to describe the quality of 
sounds to one who had never heard them, would 
be like describing colors to one blind. It will be 
seen hereafter that the quality of certain sounds 



32 INTRODUCTION. 

obtained by auscultation and percussion is peculiar 
to them, and their distinctive characters in this 
respect can be known only by direct observation ; 
they cannot be learned by means of any verbal 
description, nor by any comparisons — that is, by 
analogy. 

Appreciable variations in the quality of sounds 
are infinite. This may be illustrated by the human 
voice. Almost every person may be recognized from 
a peculiar quality of the voice by one who is familiar 
with it ; and the voices of thousands of persons, if 
compared, would present shades of difference — in 
fact, as is well known, it is extremely rare for the 
voices of any two persons to be so nearly identical 
in quality that they cannot be distinguished from 
each other. As the diversity in quality of different 
sounds cannot be described, so they can only be 
designated by names which are significant from 
certain resemblances. Terms based on analogies 
which are used to denote qualities of the sounds 
furnished by auscultation and percussion are the 
following : rough, harsh, and rude, soft, blowing, 
hollow, musical, moist, dry, bubbling, gurgling, 
crackling, clicking, rubbing, grating, creaking, tu- 
bular, cracked metal, sibilant or whistling, sonorous 
or snoring. All these names owe their significance 
to resemblances to other sounds. One sound fur- 
nished both by auscultation and percussion has a 
quality which is sui generis, and the term used to 
distinguish it is derived from its source, namely, the 
vesicular resonance, and the vesicular murmur of 
respiration. 



HEALTHY AND MORBID SIGNS. 3-3 

111 addition to intensity, pitch, and quality, as 
sources of the distinctive characters of the signs 
furnished by auscultation and percussion, there are 
some other points of difference, namely, the duration 
of certain sounds, their continuousness or otherwise, 
their apparent nearness to, or distance from, the ear, 
their rhythmical succession, and their strong resem- 
blance to particular sounds, such as the bleating of 
the goat, the chirping of birds, etc. These points of 
difference are important, although less so than those 
relating to intensity, pitch, and quality. 

The study of the different sounds furnished by 
auscultation and percussion, with reference to dis- 
tinctive characters relating especially to intensity, 
pitch, and quality, distinct signs being determined 
from points of difference as regards these characters, 
may be distinguished as the analytical method. It 
may be so distinguished in contrast with the deter- 
mination of signs deductively, taking as a stand- 
point either the physical conditions incident to 
diseases or the sounds. If we undertake to decide, 
a priori, that certain sounds must be furnished by 
auscultation and percussion when certain conditions 
are present, we shall be led into error; and so, 
equally, if we undertake to conclude from the nature 
of the sounds that they must represent certain con- 
ditions. The only reliable method is to analyze the 
sounds with reference to differences relating espe- 
cially to intensity, pitch, and quality, and to de- 
termine different signs by these differences, the 
import of each of the signs being then established 
by the constancy of association with physical condi- 



34 INTEODUCTION. 

tions. It is by this analytical method only that the 
distinctive characters of signs can be accurately and 
clearly ascertained. This is to be borne in mind by 
the student in physical exploration. He is to be- 
come acquainted with the different signs, and to 
recognize them in practice, by acquiring a knowl- 
edge of the distinctive characters of each, as derived 
mainly from differences relating to intensity, pitch, 
and quality. The individuality of the signs, sever- 
ally, can rest on no other solid basis. 

The Significance of the Signs as regards the Physical 
Conditions which they severally represent. 

Knowledge of the significance of the physical 
signs is the complemental requirement in the study 
of auscultation and percussion. For the successful 
employment of these methods, in addition to the 
recognition of each sign by its distinctive characters, 
must be known its significance, that is, the physical 
condition which it represents. In this respect the 
signs may be compared to the substantives in lan- 
guage, each having a definite meaning. The signs 
furnished by these methods may be said to consti- 
tute a language with a very small vocabulary ; or, 
taking as the standpoint the things signified, the 
different physical conditions are expressed by means 
of the signs. 

It is to be noted that the significance of the morbid 
signs relates immediately, not to diseases, but to the 
physical conditions incident thereto. Very few signs 
are directly diagnostic of any particular disease. 
They represent conditions not peculiar to one, but 
common to several, diseases. Thus, solidification 



REGIONAL DIVISIONS OF THE CHEST. 35 

of lung exists in pneumonia, phthisis, pleurisy with 
effusion, collapse, and pulmonary cancer ; now, 
certain signs tell us that this morbid condition 
exists, together with its situation, its degree, and its 
extent. With this information the diagnosis of the 
disease is made by connecting with it pathological 
laws, together with the history and symptoms. The 
student in physical exploration should by no means 
imagine that, for the diagnosis of diseases, exclusive 
reliance is to be placed on the signs ; they are always 
to be taken in connection with pathological laws, the 
history, and the symptoms. Disconnected from these, 
the signs would often lead to error, and it is no dis- 
paragement to physical diagnosis that its reliability 
depends on other facts than those which belong ex- 
clusively to it. 

To repeat a statement already made more than 
once, the significance of the signs, as regards the 
conditions which they severally represent, is based 
on the constancy of their association with the latter, 
our knowledge of this association being derived from 
examinations during life and after death. 

Regional Divisions of the Chest. 

Before entering on the study of physical explora- 
tion, the student should become acquainted with 
the divisions of the surfaces of the anterior, pos- 
terior, and lateral aspects of the chest into circum- 
scribed spaces which are called regions. These 
divisions, deriving their boundaries and names 
from their anatomical relations, are sufficiently 
simple. 

Anteriorly the chest is divided into regions as 



36 



INTRODUCTION. 



follows : The supra- or post-clavicular region ex- 
tends from the clavicle upward a short distance, 




The horizonUl lines indualc tlip liduuddiip- of tlic ict;i(mal divisions on the an- 
terior aspect of tlie chest. Tlie vertical line is the linea mamillaris. The oblique 
dotted lines indicate the interlobar fissures. 

ab, ac, cd, and hd, boundaries of superficial cardiac space, ih, outer boundary of 
deep cardiac space; ce, lower boundary of right lung; df, lower boundary of left 
lung ; gli, upper boundary of right and left lung ; Imi, lower boundary of hepatic flat- 
ness ; pq, upper boundary of hepatic dulness ; no, lower boundary of the stomach 
moderately distended. 



EEGIONAL DIVISIONS OF THE CHEST. 



37 



corresponding to the variable height to which the 
lung rises above this bone. The clavicular region 



Fig. 2 



l^ 




The longitudinal and vertical lines indicate the regional divisions on the posterior 
aspect of the chest. 

ab, lower boundary of lungs ; cd, lovcer limit of expansion of lungs ; ef, interlobar 
fissures ; h, spleen ; i, lower boundary of liver ; Jc, left kidney ; I, right kidney. 

embraces the space occupied by the clavicle. The 
infra-clavicular region embraces the space between 

4 



38 



INTRODUCTION. 



the clavicle and the third rib. The mammary 
region is bounded above by the third and below 
by the sixth rib, and the infra-mammary region is 
the portion of the chest below the sixth rib. 



Fig. 3. 





The horizontal line indicates the regional division of the lateral aspect of the chest. 
ab, lower boundary of right lung ; ed, lower boundary of hepatic flatness ; ef, upper 
boundary of hepatic dulness ; g, border of kidney. 



REGIONAL DIVISIONS OF THE CHEST. 39 

Posteriorly the divisions are into the scapular, 
the infra-scapular, and inter-scapular regions. The 




ah, boundary of hepatic flatness ; cd, lower bovindary of left lung ; e, /, g, h, i, k, I, 
boundaries of spleen ; Im, boundary of kidney ; q, r, s, lower boundaries of the 
stomach in different degrees of distention. 

scapular region is the space occupied by the scapula, 
and is divided by the spinous ridge into the upper 



40 INTRODUCTION. 

and lower scapular space. The infra-scapular region 
is the portion below a horizontal line intersecting 
the lower angle of the scapula. The inter-scapular 
region is the space between the posterior margin of 
the scapula and the spinal column. 

Laterally there are two regions, namely, the ax- 
illary and the infra-axillary. The axillary region is 
the space above a horizontal line extending from 
the lower border of the mammary region, i. e., the 
sixth rib. The infra-axillary region is the portion 
below the axillary region. 

The portion of the anterior surface occupied by 
the sternum is divided into the upper and the lower 
sternal region, the space above the sternal notch 
being the supra-sternal region. 

In order to become familiar with the foregoing 
regional divisions, it is recommended to the student 
to delineate them with ink on the chest of the living 
subject or a cadaver. Figs. 1, 2, 3, 4. 

It is advisable to study sections, extending from 
the surface to the centre of the chest, corresponding 
to the different regions, so as to become familiar 
with the relation of each section to the parts con- 
tained within it. An enumeration of the more im- 
portant of the anatomical relations of the different 
regions is as follows : 

1. Supra- clavicular Region. — This is relative to the 
upper extremity or apex of the lung, which rises 
above the clavicle in different persons from half an 
inch to an inch and a half. The height is generally 
greater on one side, and this side is usually the left. 

2. Clavicular Region. — A small portion of the lung 



REGIONAL DIVISIONS OF THE CHEST. 41 

at or near the apex is contained in the section cor- 
responding to this region. 

3. Infra-clavicular Region. — The parts situated 
here, exclusive of the upper sternal region [vide 
No. 7), are the upper portion of the lung, and the 
extra-pulmonary bronchi. The differences between 
the two primary bronchi, as regards direction, size, 
and length, are important points in the study of this 
section. 

4. Mammary Region. — The differences between 
the two sides in the sections corresponding to this 
region are important. These differences relate es- 
pecially to the prsecordia, and are involved in the 
physical diagnosis of enlargement of the heart. 
The commencement of the interlobular fissures is 
in this region. On the left side the fissure is 
between the fourth and fifth ribs. On the right 
side the fissure between the upper and middle lobes 
begins at the fourth costal cartilage, and between 
the middle and lower lobes a short distance below. 
The situations of the fissures, however, differ con- 
siderably during the acts of inspiration and expi- 
ration. 

5. Infra-mammary Region. — This region differs in 
its anatomical relations considerably on the two 
sides of the chest. On the right side the liver 
pushes upward the diaphragm nearly or quite to 
the upper boundary, namely, the sixth rib. On the 
left side the section corresponding to the region 
embraces, together with the anterior portion of the 
lower lobe of the lung, portions of the stomach, 
spleen, and the left lobe of the liver. The variable 
volume of the stomach at different times occasions 

4* 



42 INTRODUCTION 

considerable variations in the relative spaces occu- 
pied by these different parts. 

6. Supra-sternal Region. — This region is in relation 
to the trachea. 

7. The Upper Sternal Region. — The bifurcation of 
the trachea is beneath the sternum at the centre of 
a line connecting the second ribs. Below this line 
the lungs on the two sides are nearly in contact at 
the mesial line, covering the primary bronchi. 

8. Lower Sternal Region. — The sternum in this re- 
gion covers a large portion of the right and a little 
of the left ventricle. 

9. Scapular Region. — The sections corresponding 
to this region contain the posterior portion of the 
upper lobe and a portion of the upper part of the 
lower lobe of the lung. At the upper part of the 
lower scapular space terminates the fissure separat- 
ing the upper and the lower lobe. The line of this 
fissure pursues an oblique course to the fourth or 
fifth rib on the anterior aspect of the chest. 

10. Infra- scapular Region. — On the right side the 
lung extends from the upper boundary of this re- 
gion to the eleventh rib, the liver rising to the latter 
point. On the left side the section contains a por- 
tion of the spleen. 

11. Inter-scapular Region. — The trachea extends in 
this section to the fourth dorsal vertebra, where it 
bifurcates. Below this point, on the two sides, are 
situated the primary bronchi. 

12. Axillary Region. — The section corresponding 
to this region contains a portion of the upper lobe 
with large bronchial tubes. 



REGIONAL DIVISIONS OF THE CHEST. 43 

13. Infra-axillary Begion. — This is in relation to 
the upper part of the liver on the right side, and on 
the left side to a portion of the spleen and stomach, 
the remainder of the section occupied by lung. 

It is recommended to the student to become fami- 
liar with the sections corresponding to the different 
regions, by dissections for this purpose, and the 
study of anatomical illustrations. Figs. 1, 2, 3, 4. 

Asking the student's careful attention to the in- 
troductory considerations which have been pre- 
sented, auscultation and percussion in health and 
disease, and the physical signs involved in the diag- 
nosis of diseases of the respiratory system and of the 
heart, will be considered as follows : Chapter II., 
Percussion in Health; Chapter III., Percussion in 
Disease; Chapter lY., Auscultation in Health; 
Chapter Y., Auscultation in Disease; Chapter YL, 
The Physical Diagnosis of the Diseases of the Respi- 
ratory System ; Chapter YIL, The Physical Condi- 
tions of the Heart in Health and Disease ; Chapter 
YIII., The Physical Diagnosis of Diseases of the 
Heart ; and, as properly embraced in the scope of 
this treatise, Chapter IX. will be devoted to the 
Diagnosis of Thoracic Aneurisms. 



CHAPTER II. 

PEECUSSION IN HEALTH. 

Percussion with the fingers or with a pereussor and pleximeter — The 
normal vesicular resonance on percussion; its distinctive characters 
relating to intensity, pitch, and quality — Variations in the characters 
of the normal vesicular resonance in different persons — Relation of the 
pitch of resonance to the vesicular quality— Tympanitic resonance over 
the abdomen — Variations of the normal resonance in the different re- 
gions of the chest— Enumeration of the regions in which the resonance 
on the two sides varies, and those in which it is identical in health — 
Influence of age on the normal resonance — Influence of the acts of 
respiration on the resonance — Rules in the practice of percussion. 

Percussion may be performed with either the 
lingers or artificial instruments. The fingers suffice 
for the study and in ordinary practice. Instruments 
are preferable only when it is desired to produce 
sounds to be heard at a distance, as in class illustra- 
tions, and when, from the number of patients to be 
percussed, as in dispensary or hospital practice, the 
frequent repetition of the blows renders the fingers 
tender and painful. The instruments are a plexi- 
meter and a pereussor. A simple and convenient 
pleximeter is an oval disk of ivory or hard India- 
rubber, with projecting handles or auricles suffi- 
ciently large and roughened on their outer aspect 
so as to be conveniently held by the fingers. The 
author has lately used with satisfaction a plexi- 
meter consisting of a piece of hard rubber bent up- 
ward at one extremity, and ending in a handle. 



NORMAL RESONANCE. 



45 



(Fig. 6.) The best percussor is a double cone of 
caoutchouc encircled at its centre with a handle of 
convenient length and size, the ring and the handle 
made of vulcanized rubber. The instrument is very 
durable. (Fig. 7.) 

Fig. 5. 




Kiibber Pleximeter. 



When percussion is performed with the fingers, 
the palmar surface of One or more of those of the 
left hand should be applied to the chest, with 



Fig. 6. 




pressure sufficient to condense the soft structures, 
and the blows are given with one or more of the 
fingers of the right hand bent at the second phalan- 



FlG. 




Flint's Percussor. 



geal joint so as to form a right angle. In giving the 
blows, the movements should be limited to the wrist- 



46 PERCUSSION IN HEALTH. 

joint, the ends, not the pulp, of the percussing fingers 
being brought into contact with the dorsal surface of 
the finger or fingers applied to the chest. The per- 
cussing fingers should be withdrawn instantly the 
blow is given. The type of perfect percussion is 
the movement of the hammers when the keys of a 
piano-forte are struck. The force of the percussion 
should never be suflicient to give pain to the pa- 
tient; generally either light or moderately forcible 
blows sufiice. The requisite tact in the perform- 
ance of percussion is acquired by a little practice. 

The first object in the study of percussion is to 
become acquainted with the characters which are 
distinctive of the sound obtained thereby from the 
healthy chest. For this object the percussion may 
be made either in the infra-clavicular region of 
either side, or in the infra-scapular region, the 
sound in these situations being louder than in other 
regions. Percussion being performed, a sound or 
resonance is produced. This sound or resonance is 
now to be analyzed with reference to characters de- 
rived from intensity, pitch, and quality. What are 
these characters? The intensity will depend, other 
things being equal, on the force of the blow; the 
resonance is comparatively feeble with a slight, and 
loud with a strong, percussion. Other circum- 
stances affect the intensity, irrespective of the force 
of the blow, namely, the volume of the lung, the 
elasticity of the costal cartilages, and the thickness 
of the soft parts which cover the chest. Owing to 
these circumstances, the intensity of the resonance 
is by no means similar, in the same situation, in all 
healthy persons; it is comparatively feeble in some 



J^ORMAL RESONANCE. 47 

and loud in others. There is nothing distinctive of 
this normal resonance to be derived from intensity, 
and we say, therefore, that the intensity is variable. 

What is the pitch of this normal resonance ? The 
pitch of a sound is always relative; and, comparing 
this resonance with all the morbid signs obtained 
by percussion, it is lower in pitch. We say, there- 
fore, that the pitch of this normal resonance is low. 
The pitch, however, is found to vary in different 
healthy persons. 

What is the quality of this normal resonance ? It 
has a quality which is peculiar to it. In this respect 
it is not identical with any sound produced other- 
wise than by percussion over healthy lung either 
within or without the chest. The quality cannot, 
therefore, be learned by analogy, nor can it be de- 
scribed ; it can only be appreciated by direct obser- 
vation. The peculiar quality is due to the fact that 
the resonance is from air contained in the pulmonary 
vesicles. This arrangement causes the peculiar 
quality, just as the construction of any particular 
musical instrument causes the quality of tone pecu- 
liar to that instrument; hence, as it is convenient 
to give the quality a name, we call it the vesicular 
quality. This quality is not equally marked in all 
healthy persons, being as a rule more marked in 
proportion to the intensity of the resonance. 

This vesicular quality, as just noted, is peculiar to 
the pulmonary resonance. An approximative repre- 
sentation of it is obtained by percussing either a 
sponge or a loaf of bread. The latter gives a closer 
imitation than the former. Each of these articles 
affords a resemblance to the vesicular quality of reso- 



48 PERCUSSION IN HEALTH. 

nance, for the reason that it contains air in an 
infinite number of small spaces, in this regard re- 
sembling the lungs. In order to represent this sign 
by percussing a loaf of bread, the loaf should be 
covered with a napkin, in order to lessen the noise 
produced by the contact of the finger or the percus- 
sor, and thus to elicit better resonance from the air 
contained in the interstices of the loaf. The upper 
crust stands in place of the thoracic wall. The 
resonance elicited illustrates the lowness of pitch 
with a pretty close approach to the peculiar quality 
of the normal vesicular resonance. 

The normal resonance, then, obtained by percus- 
sion, may be thus defined : 

A resonance of variable intensity, low in pitch 
and having a peculiar quality called vesicular. The 
word vesicular is frequently embraced in the name 
of this healthy sign ; it is also called the normal 
resonance, the normal pulmonary resonance, or the 
normal vesicular resonance. The last of these names 
is to be preferred. 

The normal vesicular resonance on percussion, as 
has been seen, is not uniform in all healthy persons ; 
not only is its intensity variable, but it varies in 
pitch and in the amount of vesicular quality. This 
may be easily illustrated by percussing successively 
in the same situation, and with the same force, a 
series of persons who are assumed to be free from 
disease. Is there not in this fact an obstacle in 
practically determining this healthy sign ? The 
fact occasions no embarrassment for this reason : 
we determine, in each case, that the resonance is 
normal by a comparison of the two sides of the 



VARIATIONS IN NORMAL RESONANCE. 49 

chest, percussing in corresponding situations on the 
two sides and with the same force. There is no 
ideal standard of the normal vesicular resonance, 
but, by comparing the two sides of the chest, the 
standard of health proper to each person is obtained. 
The laws of disease are such that, for all practical 
purposes, the standard of health is in this way almost 
always available. ^Notwithstanding the variations 
within the range of health, the lowness in pitch and 
the vesicular quality are sufficiently distinctive of 
this normal sign as compared with the morbid signs. 

The pitch of the vesicular resonance and its vesic- 
ular quality are in a uniform relation to each other; 
that is, the conditions giving rise to the peculiar 
quality also render the pitch low. In proportion 
as the vesicular quality is marked, the pitch is 
lowered, and, conversely, with diminution of the 
vesicular quality the pitch is relatively higher. This 
relation between the pitch and quality will be found 
to hold good in the resonance modified by disease 
as well as in health. Another relation may be here 
stated, namely, whenever, in health or disease, a 
tympanitic quality is combined with the vesicular, 
and in proportion as the former predominates, the 
pitch of the resonance is raised. 

The pitch and quality of the normal vesicular 
resonance may be readily illustrated by percussing 
successively over the chest and the abdomen. The 
different sections of the alimentary canal generally 
containing more or less gas, a resonance is obtained 
by percussion over the abdomen. This resonance 
is, of course, devoid of the vesicular quality ; in con- 
tradistinction to the latter, its quality is called tym- 



50 PERCUSSION IN HEALTH. 

panitic. This tympanitic resonance is not uniform 
in all parts of the abdomen, but everywhere the 
quality is tympanitic, that is, non-vesicular, and the 
pitch is everywhere higher than that of the normal 
vesicular resonance. The tympanitic resonance 
over the stomach is generally high in pitch, and 
frequently has a ringing or metallic intonation. 
The gastric tympanitic resonance recognized by 
these characters, will be found to be involved fre- 
quently in sounds produced by percussing over the 
chest. Gas in the csecum gives a still higher pitch 
of resonance. Over the colon the resonance is lower 
than over the caecum and stomach, and it is still 
lower over the small intestines. In all these situa- 
tions, bringing the tympanitic in contrast with the 
normal vesicular resonance, the peculiar quality of 
the latter and its lowness of pitch are rendered ap- 
parent. ■ The term tympanitic resonance v^ill be 
found to enter into the names of two of the morbid 
signs obtained by percussion. 

Having studied the characters of the normal 
vesicular resonance, and become practically familiar 
with them by percussing different healthy persons, 
the student should study the variations which this 
resonance presents in the ditferent regions of the 
chest. In doing this he acquires more and more 
tact in the performance of percussion, and becomes 
more and more familiar with the characters in 
general of the normal vesicular resonance. 

Supra, or Post-clavicular Region. — The resonance 
here varies much in intensity in diiierent persons. 
The vesicular quality is most marked in the central 
portions. Towards the sternal extremity the reso- 



RESONANCE IN DIFFERENT REGIONS. 51 

nance acquires a tympanitic quality from the prox- 
imity to the trachea ; it becomes vesiculo-tympanitic, 
a term which will be applied to one of the morbid 
signs. 

Clavicular Region. — Fear the sternum the reso- 
nance is somewhat tympanitic from the proximity 
to the trachea. At the central portion the vesicular 
quality is more or less marked, and the intensity is 
diminished at the acromial extremity. 

Infra-clavicular Region. — The resonance in this re- 
gion is more intense than elsewhere, except in the 
axillary and the infra-scapular regions. The vesic- 
ular quality is combined with a tympanitic quality 
toward the sternum, the latter being derived from 
the primary and secondary bronchi. As always 
when the vesicular and the tympanitic quality are 
combined, the pitch is raised. This combination in 
health and disease is recognized by the intensity, 
pitch, and quality. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular re- 
gion, owing to the presence of the scapula and its 
muscles. In proportion as the intensity is less, the 
vesicular quality is less marked. The resonance in 
health, however, is quite sufficient for morbid signs 
to be available in this situation. 

Inter-scapular Region. — The resonance in this re- 
gion is weak in comparison with other regions, ex- 
cept the scapular, owing to the muscles which here 
cover the chest. In the upper part of the region 
the resonance is somewhat tympanitic from the re- 
lation to the trachea and bronchi. 



62 PERCUSSION IN HEALTH 

Mammary Region. — The right and the left mam- 
mary region are to be studied with reference to 
differences relating to the liver and the heart. On 
the right side, from the fourth rib downward, the 
resonance is diminished, the convex extremity of 
the liver extending up to this height. At or a little 
below the lower border of this region on the mam- 
mary line, that is, a vertical line passing through the 
nipple, resonance ceases, the lower lobe of the right 
lung not extending below this point. Between the 
third and fifth ribs on this side near the sternum, 
the resonance is diminished, from the presence of a 
portion of the right auricle and ventricle. On the 
left side the resonance is diminished, within the prse- 
cordial space. This space extends vertically from 
the third rib to the fifth intercostal space, and hori- 
zontally from the sternum to a point at or a little 
within the mammary line. The resonance is con- 
siderably diminished within what is called the 
superficial cardiac space. This space may be rep- 
resented by a right-angled triangle, the right angle 
formed by a vertical line drawn from a point on the 
median line intersected by a horizontal line connect- 
ing the fourth ribs, and a horizontal line intersecting 
the point of apex-beat in the fifth intercostal space ; 
an oblique line drawn from the centre of the sternum 
on a level with the fourth rib and the point of apex- 
beat forms the hypotheuuse of the right-angled 
triangle. This oblique line is, in fact, a curved, 
not a straight, line {vide Fig. 1, p. 36), the convexity 
looking to the left side. Practically, however, it is 
near enough to accuracy to consider it the hypothe- 
nuse of a right-angled triangle. Within this space 



RESONANCE IN DIFFERENT REGIONS. 53 

the heart is in contact with the thoracic wall. With- 
out this space and within the prsecordia the heart is 
covered with lung, and the resonance on percussion 
is less diminished. It is a useful exercise for the 
student to observe the diminution of the area of the 
superficial cardiac space by a forced inspiration, as 
determined by percussion. Aside from the presence 
of the heart and the convex extremity of the liver, 
the resonance over the mammary is less than in the 
infra-clavicular region, being diminished by the pec- 
toral muscle, which varies considerably in bulk in 
different persons, and in women by the mammary 
gland, the size of the latter varying very much in 
different women. The development of the mammge, 
however, is never so great as to preclude the useful 
employment of percussion in this region. 

Infra-mammary Region. — In this region, as in the 
region above it, the two sides present notable differ- 
ences owing to the situation of the organs below the 
diaphragm. On the right side, over the greater part, 
and sometimes the whole of this region, resonance 
is wanting, that is, percussion gives flatness. It is 
easy to delineate the boundary between the lower 
border of the right lung and the liver, or, as it is 
called, the line of hepatic flatness. It is also easy to 
distinguish above this line the height to which the 
upper extremity of the liver extends, or, as it is 
called, the line of hepatic dulness. The situation of 
both these lines varies considerably in different 
healthy persons. The distance between the two 
lines is from one to two inches. Both lines are 
affected considerably by a forced inspiration and a 
forced expiration. A forced inspiration depresses 



54 PERCUSSION IN HEALTH. 

the line of flatness about one and a half inch. A 
forced expiration causes the line to rise from two 
and a half to five and a half inches. The distance, 
therefore, between this line at the end of a forced 
expiration, and at the end of a forced inspiration 
varies from four to seven inches. With reference 
to the practice of percussion, as well as for the pur- 
pose of verification, these points should be studied. 
ISTot infrequently percussion over the right infra- 
mammary region yields a tympanitic resonance due 
to the distention with gas of the transverse colon. 

On the left side, the resonance in this region varies 
in different persons, in the same persons at different 
times, and in different portions of the region at the 
same time, the variations depending on the organs 
below the diaphragm. Flatness is caused by the 
extension of the left lobe of the liver into this re- 
gion about three inches to the left of the median 
line. The left portion of the region is in relation to 
the spleen, an organ which varies considerably in 
size in health as well as disease, its average dimen- 
sions being about four inches in length and three 
inches in width. Between the spleen and the liver 
lies the stomach, the volume of which is constantly 
fluctuating, owing to its varying solid, liquid, and 
gaseous contents. Distention of the stomach with 
gas occasions a tympanitic resonance which fre- 
quently is transmitted above into the mammary re- 
gion in health as well as in disease. The space 
corresponding to the spleen is determined by the 
vesicular resonance above and the tympanitic reso- 
nance below, the latter boundary, however, not 
being very reliable on account of the ready conduc- 



RESONANCE IN DIFFERENT REGIONS. 55 

tion of tympanitic resonance for a certain distance. 
The distention of the stomach with solid or liquid 
contents, of course, occasions flatness. The stud}' 
of the infra-mammary regions with reference to the 
variations in resonance arising from the relations to 
the organs below the diaphragm, is of much utility 
from the practice, as well as the knowledge, which 
it involves. The exercise, of endeavoring to define 
the boundaries of these different organs in healthy 
persons, will be of great service to the student in 
acquiring tact in percussion, and in discriminating 
differences in the sounds obtained by this method. 

Sternal Regions. — In the upper sternal region, that 
is, above the lower margin of the second rib, the 
resonance is non-vesicular, being derived from air 
in the trachea above the point of bifurcation. Being 
non-vesicular, it is, of course, tympanitic, inasmuch 
as the resonance is always tympanitic in quality if 
wholly- devoid of the vesicular quality. Between 
the second and third ribs, the inner borders of the 
two lungs approximating, the resonance has a ves- 
icular quality more or less marked; but owing to 
the remnant of the thymus gland, together with 
adipose substance, and the presence of the large 
vessels, the resonance is not intense in this situation. 
Below the third rib the resonance has modifications 
due to the combination of several different organs 
situated beneath the lower sternal region. On the 
right side of the mesial line is the inner border of 
the right lung, the greater part of the right and a 
portion of the left ventricle of the heart lying be- 
neath ; a portion of the liver extends into the lower 
part of this region, and a portion of the stomach 



56 PERCUSSION IN HEALTH. 

when distended. The resonance thus varies in 
diiferent situations, and often presents a mixed 
character. It is a useful exercise to endeavor to de- 
fine by percussion the boundaries of the several 
organs which are here in juxtaposition. 

Infra-scapular Regions. — The resonance below the 
scapula is intense as compared with that over the 
scapula, and the vesicular quality is marked. The 
resonance extends to the eleventh rib, which is the 
lower boundar}' of the lung. On the right side, at 
or near this point, is the line of hepatic flatness, 
hepatic dulness extending from one to two inches 
above this line. The line of hepatic flatness and of 
hepatic dulness is lowered from one to two inches 
by a deep inspiration, and raised by a forced expira- 
tion. On the left side the resonance may receive a 
tympanic quality from the presence of gas in the 
stomach. 

Lateral Regions. — In these regions the resonance 
is relatively intense, and notably vesicular. On the 
right side the line of hepatic flatness is at the eighth 
rib, hepatic dulness extending above this line as in 
front and behind. On the left side the resonance 
may be rendered somewhat dull b}' the presence of 
the spleen, but it often has a tympanitic quality from 
the presence of gas in the stomach. 

As has been stated, the normal vesicular resonance 
is not in all persons identical as regards intensity, 
pitch, and quality. There is, therefore, no fixed 
standard in these respects by which we can deter- 
mine whether the resonance be normal or not. The 
standard proper to each person is to be ascertained 
by a comparison of the two sides of the chest ; each 



RESONANCE IN DIFFERENT REGIONS. 57 

person, in other words, furnishes his own standard of 
health. But it is to be observed that all the regions 
do not normally correspond in respect of the reso- 
nance on the two sides. In the following regions the 
resonance is notably dissimilar on the two sides : The 
mammary, the infra-mammary, the infra-axillary, and 
the infra-scapular. There is less disparity in the 
resonance on the two sides in the following regions : 
The supra-clavicular, clavicular and infra-clavicular, 
the sca,pular and inter-scapular, and the axillary. 
In some of these regions, however, the resonance 
diiiers, and it is of practical importance to note the 
dissimilarity which thus belongs tO health. This 
statement applies especially to the infra-clavicular 
region, a region which, as will be seen hereafter, is 
of great importance with reference to the signs of 
phthisis. In this region the resonance on the left 
side is somewhat more intense, more vesicular, and 
lower in pitch than is the resonance on the right 
side ; per contra, the resonance is less intense, less 
vesicular, and higher on the right side. This ac- 
count of these points of disparity between the two 
sides is based on an analogy of recorded observa- 
tions in a series of healthy persons.^ The student 
should become practically familiar with the normal 
differences between the two sides, and in becoming 
so, the practical experience acquired in performing 
percussion will be of use. 

The normal resonance is affected by age. In 
early life, when the costal cartilages are flexible and 
elastic, the resonance is more intense and lower in 

1 Vide Physical Exploration of the Chest by the Author, 1856. 



68 PERCUSSION IN HEALTH, 

pitch than in old age, when the cartilages are rigid 
and the vesicular structure of the lung more or less 
atrophied. 

The resonance varies considerably in the different 
regions at the end of a full inspiration and at the 
end of a forced expiration. With regard to this 
disparity, the following is an extract from a work 
on physical exploration, published by the author in 
1856: 

"The percussion-sound may also be found to vary 
at different periods of an act of respiration in the 
same individual. The quantity of air contained 
within the air-cells, and consequently the relative 
proportion of air and solids, are by no means equal 
after a full inspiration and after a forced expiration. 
The difference in lung expansion may occasion an 
appreciable disparity in resonance, according as the 
percussion is made at the conclusion of a full in- 
spiration, or a forced expiration. The disparity is 
not appreciable uniformly in different persons. This 
fact I have ascertained by noting the results of ex- 
aminations made with reference to the point. When 
it does exist, it usually consists, contrary to what 
might perhaps have been anticipated, and the re- 
verse of what is usually stated in works on physical 
exploration, in diminished resonance and elevation 
of pitch at the conclusion of inspiration. This is 
probably to be explained by the greater degree of 
tension of the lungs and thoracic walls produced by 
inspiration voluntarily prolonged and maintained — 
a condition presenting physical obstacles to sonorous 
vibrations more than sufficient to counterbalance the 
increased proportion of air within the cells. It is a 



RESONANCE IN DIFFERENT REGIONS. 

curious fact, worthy of notice, that the two sides of 
the chest are not always found to be affected equally 
as regards the percussion-sound, at the conclusion 
of a full inspiration, contrasted with that after a 
forced expiration. I have observed the contrast to 
be more striking on the right than on the left side ; 
and in one instance on the left side, the resonance 
was less intense and somewhat tympanitic after a 
full inspiration, while on the right side the opposite 
effect was produced, and the sound became quite 
dull after a forced expiration. In view of these 
variations in a certain proportion of instances inci- 
dent to different periods of a single act of respira- 
tion, in some cases of disease in which it is desirable 
to observe great delicacy in the correspondence of 
the tw^o sides, pains should be taken to percuss cor- 
responding points at a similar stage of respiration, 
and the close of a full inspiration is, perhaps, the 
period to be preferred. Ordinarily, the liability to 
error from this source is obviated, either by repeat- 
ing a series of strokes, first on one side and next 
on the other, or by percussing both sides repeatedly 
in quick succession, in order mentally to obtain the 
average intensity and other characters of the sound 
during the successive -stages of a respiration. The 
instances of disease, however, are exceedingly rare, 
in which such nicety of discrimination is important." 
Prof. Da Costa has recently studied more fully the 
variations in this respect in the different regions in 
disease as well as in health, and he has distinguished 
this as " respiratory percussion. '"^ 

1 Vide work on Diagnosis, fourth edition, 1876. 



60 PERCUSSION IN HEALTH. 



Rules in the Practice of Percussion. 

1. Prior to a comparison of the two^ sides of the 
chest, as regards the resonance on percussion, either 
in health or disease, an examination by inspection 
should be made, in order to determine whether 
there be any deviation from the normal conforma- 
tion. In what has been stated concerning percus- 
sion in health, it is assumed that the chest is 
symmetrical. Want of symmetry may be due to 
congenital deformities, and to those caused by ra- 
chitis, chronic pleurisy, curvature of the spine, and 
injuries. Any deviation from the normal conforma- 
tion will affect more or less the resonance in corre- 
sponding regions on the two sides. Due allowance 
is to be made for want of symmetry in determining 
morbid signs, and often the existence of these cannot 
be determined with positiveness when there is con- 
siderable deformity. The signs obtained by auscul- 
tation are less affected by want of symmetry than 
those obtained by percussion. 

2. Attention to the position of the person exam- 
ined is important with reference to the normal sym- 
metry of the chest. If the person be standing or 
sitting, the position should be upright and the 
shoulders brought to a level. A little inclination 
of the body to one side, or a depression of one 
shoulder, will be found to affect perceptibly the 
normal resonance, when the two sides are com- 
pared. If the body be recumbent, it should be as 
nearly as possibly on a level plane. These condi- 



EULES IN PRACTICE OF PERCUSSION. 61 

tions are indispensable for a nice comparison of the 
two sides either in health or disease. 

3. In making a nice comparison, the person who 
percusses should be, as nearly as possible, either in 
front or behind the person percussed. Percussion 
made by one standing or sitting by the side of the 
person percussed, is almost certain to produce dis- 
parity in resonance. 

4. Percussion made successively on one side and 
the other side, must be in all respects the same in 
regard to the mode, the force of the blow, and the 
situation. A light percussion on. one side, and a 
strong percussion on the other side, will, of course, 
cause a disparitj^ in the intensity of resonance. The 
percussion must be made in succession at points as 
nearly as possible equidistant from the median line, 
and from the summit or base of the chest. With 
reference to great nicetj^, the percussion, if made on 
the rib or intercostal space on one side, must be 
made on the rib or intercostal space on the other 
side. Great nicety of comparison also requires that 
if the percussion be made on one side during the 
act of inspiration, it should be made on the other 
side during this act. The signs of disease, however, 
are generally so well marked, that very close atten- 
tion to these points is not necessary. 

5. A series of blows in rapid succession (5 or 7) is 
to be preferred to one or two, in practising percus- 
sion, difference in intensity, pitch, and quality being 
thereby better appreciated. 



62 PERCUSSION IN HEALTfl. 

6. Percussion may be made lightly or forcibly, 
the former being called superficial, and the latter 
deep percussion. With light blows the resonance 
comes from the superficies of the lung and from 
within a limited area. With forcible blows the 
resonance is from a greater depth and a wider 
space. The result of these different modes of prac- 
tising percussion may be illustrated within the prse- 
cordia in health. Comparing the resonance over 
the superficial cardiac space with that in a corre- 
sponding situation on the right side, dulness is more 
marked with light than with forcible blows, the 
resonance from the latter coming from a wider area. 
On the other hand, comparing the resonance over 
the deep cardiac space, dulness is more marked with 
forcible than with light blows, owing to the presence 
of lung between the heart and the walls of the chest. 
This rule is of importance in its application to per- 
cussion in disease. 

7. Percussion over the anterior portion of the 
chest, the person percussed leaning against a door, 
a board partition, or a lathed wall, gives an increased 
intensity of resonance. It is often useful to resort 
to this procedure in the practice of percussion. 



CHAPTER III. 

PEECUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion — Require- 
ments for a practical knowledge of these signs — The distinctive 
characters of the morbid physical conditions represented by, and the 
different diseases into the diagnosis of which enter, the signs, sever- 
ally, to wit, 1. Absence of resonance or flatness ; 2. Diminished reso- 
nance; 3. Tympanitic resonance; 4. Vesiculo-tympanitic resonance 
5. Amphoric resonance: 6. Craoked-metal resonance — Sense of resist- 
ance felt in the practice of percussion, as a morbid sign. 

Percussion in cases of disease furnishes signs 
which represent morbid physical conditions incident 
to the different pulmonary affections; with these 
physical conditions and their relations to pulmonary 
affections the student is supposed to be familiar {vide 
page 20 et seq.). 

The signs of disease furnished by percussion are 
resolvable into six, namely: 1. Absence of reso- 
nance or flatness ; 2. Diminished resonance or dul- 
ness ; 3. Tympanitic resonance ; 4. Yesiculo-tym- 
panitic resonance; 5. Amphoric resonance, and 6, 
Cracked-metal resonance. The two last named 
signs are properly varieties of tympanitic resonance, 
but it is most convenient to consider them as dis- 
tinct signs. 

Knowledge of these six signs sufficient for their 
availability in physical diagnosis requires, first, a 
practical acquaintance with the characters which 
distinguish each from] the others, as^well as from 



64 PERCUSSION IN DISEASE. 

the normal resonance : and second, a clear apprehen- 
sion of the significance of each, that is, the morbid 
physical conditions which thej severally represent. 
Under these two aspects the signs will now be con- 
sidered. 

1. Absence of Resonance or Flatness. 

This sign is sufficiently defined by its name. It 
is absence of resonance or sound. ISTothing is heard 
but a noise such as may be produced by percussing 
over a solid mass, for example, a limb composed of 
muscle and bone, or over a collection of liquid, for 
example, the abdomen in hydro-peritoneum or 
ascites. There being no resonance or sound, the 
sign has no characters pertaining to pitch or quality. 
It may be illustrated on the healthy chest by percuss- 
ing in the right infra-mammary region below the 
line of hepatic flatness. 

There are four classes of morbid physical condi- 
tions giving rise to flatness on percussion, namely, 
1st, the presence of liquid either in the pleural sac 
or in pulmonary cavities; 2d, liquid filling the air- 
vesicles; 3d, complete solidification of lung; and, 
4th, a tumor within the chest. Flatness on percus- 
sion always represents one of these morbid physical 
conditions. 

These conditions are incidents to different dis- 
eases, as follows : 

1st. Liquid in the pleural cavity is incident to 
pleurisy with efiFusion, empyema, and hydrothorax. 
A collection of pus constitutes pulmonary abscess, 
and phthisical cavities, or those caused by circum- 



ABSENCE OF RESONANCE OR FLATNESS. 65 

scribed gangrene, may become filled with morbid 
liquid products. 

2d. Serous effusion into the air-vesicles consti- 
tutes pulmonary oedema. Liquid blood extravasated 
characterizes hemorrhagic infaretus, pneumorrhagia 
or pulmonary apoplexy. Pus infiltrating more or 
less of the parenchyma may be derived from an ab- 
scess either within the lung, or elsewhere, for ex- 
ample, the liver, and from the pleural cavity in 
empyema when perforation of lung takes place. 

3d. Solidification of lung occurs in pneumonia 
from an exudation within the air-cells ; it is pro- 
duced by condensation from compression by liquid 
or air in the pleural sac, the pressure of a tumor, 
and by collapse; it exists in cases of phthisis, in in- 
terstitial pneumonia, and in carcinomatous infiltra- 
tion of lung. 

4th. Tumors within the chest are of difl:erent 
kinds, for examples, aneurisms and cancerous 
growths. In proportion to their size they occupy 
space belonging to the lung, as well as condensing 
the latter by pressure. Flatness may also be caused 
by the encroachment of organs situated below the 
diaphragm upon the thoracic space, as in cases of 
enlargement of the liver and spleen. 

Flatness on percussion in all these conditions is 
the same. The sign alone does not enable us to 
discriminate the conditions from each other, nor to 
determine the existing disease. 

Finding this sign present, the particular condition 

and the disease in each case are to be determined by 

the situation of the flatness, its extent, the associated 

physical signs furnished by auscultation, together 

6* 



66 PERCUSSION IN DISEASE. 

with the other methods of exploration, and by the 
symptomatic phenomena. 

2. Diminished Resonance or Dulness. 

The resonance on percussion is diminished, or 
there is dulness, when the solids or liquids within 
the chest are morbidly increased without increase 
in the quantity of air, the increased amount of solids 
or liquids not being sufficient to cause flatness. 
Diminution of air without increase of either solids 
or liquids, as in collapse of pulmonary lobules, also 
gives rise to dulness. We may formularize the 
physical conditions by saying that they consist in 
an abnormal proportion of solids or liquids over the 
air in the pulmonary vesicles. 

Dulness varies in degree. It may be slight, 
moderate, considerable, or great. These adjectives 
of quantity express sufficiently the variations in this 
regard. The degree of dulness corresponds to the 
amount of the relative disproportion of solids or 
liquids over the air within the chest. 

The pitch of sound is higher than that of the 
normal resonance of the persons percussed. This 
is invariable ; with dulness there is always more or 
less elevation of pitch. The quality is altered only 
in amount ; there is, of course, less vesicular quality 
in proportion as the intensity of the resonance is 
diminished. 

The characters which distinguish this sign, thus, 
are, lessened intensity of resonance, elevation of 
pitch, and weakened vesicular quality. 

The morbid conditions giving rise to this sign are 



DIMINISHED RESONANCE OR DULNESS. 67 

those which, existing in a greater degree, give rise 
to flatness. Morbid products within the pleural sac, 
serum, pus, Ij^mph, if not sufficient to cause flatness, 
give rise to dulness. The sign, therefore, occurs in 
pleurisy, empyema, and hydrothorax. The same is 
true of pulmonary oedema, hemorrhagic infarctus, 
pneumorrhagia, and purulent infiltration of lung. 
Solidification of lung, when not complete, occasions 
dulness; hence it is a sign in pneumonia, vesicular 
and interstitial, in phthisis, in condensation of lung 
from compression, in collapse of pulmonary lobules, 
and in carcinomatous infiltration. A tumor within 
the chest, not sufliciently large to cause flatness, 
gives rise to dulness. 

There are, however, some conditions giving rise 
to dulness, which are never sufficient to cause flat- 
ness. Pulmonary congestion limited to a lobe may 
diminish the resonance appreciably. The dulness 
may exist in the first stage of pneumonia, before 
solidification from pneumonic exudation has taken 
place. A layer of lymph upon the pleural surfaces 
causes dulness after the liquid eff'usion in pleurisy 
has been removed, and after the vesicular exudation 
in pneumonia is absorbed. Dulness may also be 
caused by a considerable accumulation of mucus or 
coagulated blood within the intra-pulmonary bron- 
chial tubes. 

The particular morbid condition which gives rise 
to dulness cannot be inferred from the characters of 
the sign : the sign only denotes that some one of the 
difierent morbid conditions exists. The condition 
which exists in each case, and the disease, are to be 
determined by the situation, extent, and degree of 



68 PERCUSSION IN DISEASE. 

dulness, taken in connection with the information 
derived from other methods of exploration than per- 
cussion, together with the history and symptoms. 

3. Tympanitic Resonance. 

Resonance is tympanitic wlienever it is entirely 
devoid of the vesicular quality ; in other words, any 
resonance which is non-vesicular is tympanitic. The 
leading distinctive character of the preceding sign 
(dulness) relates to intensity, whereas, the leading 
distinctive character of this sign relates to quality. 
Tympanitic resonance derives no distinctive char- 
acter from intensity ; it may be either more or less 
intense than the resonance of health in the person 
percussed. This point is to he emphasized, inas- 
much as with many the idea of tjmipanitic resonance 
involves increased intensity of sound ; a resonance, 
be it never so feeble, if it be non-vesicular, is tym- 
panitic. If, however, the resonance be quite feeble, 
it is not always easy to determine whether there be, 
or be not, any appreciable vesicular quality. The 
term used by Stokes, namely, " tympanitic dulness," 
is properly enough applied to a resonance with di- 
minished intensity, in which a vesicular (juality 
cannot be appreciated. As regards pitch, a tym- 
panitic resonance is higher than the normal vesic- 
ular resonance. If there be any exceptions to this 
rule, they are extremely infrequent. The tympanitic 
resonance over difterent parts of the abdomen is 
always higher in pitch than the resonance over 
healthy lung. 

The following are the morbid physical conditions 
which give rise to tympanitic resonance : 



TYMPANITIC RESONANCE. 69 

1st. Air in the pleural cavity. It is, therefore, a 
sign of pneumothorax. Frequently in this aiiec- 
tion the tympanitic resonance is more intense than 
the resonance of health, the pitch being always more 
or less raised. 

2d. Pulmonary cavities containing air. It occurs, 
therefore, in cases of phthisis. In this disease the 
tympanitic resonance is limited to a circumscribed 
space corresponding to the site and size of the cavity, 
whereas, in pneumothorax, it frequently exists over 
a considerable part or the whole of the aifected side 
of the chest. 

3d. Complete solidification of the whole or a part 
of the upper lobe of lung. The tympanitic reso- 
nance under these circumstances must be derived 
from the air in the lower part of the trachea and the 
bronchial tubes exterior to the lungs. This is the 
explanation of the sign in the second stage of pneu- 
monia affecting an upper lobe, and in certain cases 
of phthisis prior to the stage of excavation. Dilata- 
tion of the intra-pulmonary bronchial tubes, with 
solidification surrounding them, as in some cases oi 
interstitial pneumonia or cirrhosis of lung, may give 
rise to tympanitic resonance. 

4th. Conduction of resonance from the stomach or 
colon containing air or gas. A gastric tympanitic 
resonance is frequently conducted over a part, and 
sometimes over the whole, of the left side of the 
chest. This is more likely to occur when the left 
lung is solidified. On the right side less frequently 
a tympanitic resonance may be conducted upward 
from the colon to a greater or less extent. 

Tympanitic resonance may be illustrated by per- 



70 PERCUSSION IN DISEASE. 

cussion over the hollow abdominal viscera of the 
abdomen, provided they contain air or gas. The 
sign may be imitated by percussing an inflated 
bladder or India-rubber balls. The pitch will be 
found to vary according to the size and the 
degree of inflation of the bladder or balls. To 
illustrate this resonance in proximity to a vesicular 
resonance produced artificially, one-half of the soft 
portion of an oblong loaf of bread may be removed, 
leaving intact the upper crust. Percussion over this 
half of the loaf illustrates the tympanitic, and over 
the other half the vesicular, resonance. 

4. Vesiculo-tympanitic Resonance, 

This name was proposed by the author many 
years ago to denote a sign with the following dis- 
tinctive characters : The resonance increased in in- 
tensity ; the quality a combination of the vesicular 
with a tympanitic, and the pitch high in proportion 
as the tympanitic quality predominates over the 
vesicular. 

The sign represents especially one morbid phy- 
sical condition, namely, an abnormal accumulation 
of air in consequence of dilatation of the air-vesicles, 
that is, pulmonary or vesicular emphysema. The 
sign also is present in interstitial or interlobular em- 
physema. The relation of the sign to these affec- 
tions renders it of great value in physical diagnosis. 

A vesiculo-tympanitic resonance is obtained when 
the pleural sac is partially filled with liquid, by per- 
cussing over the lung on the affected side. Although 
the pressure of the liquid diminishes the volume of 
the lung, as a rule it yields this sign. The reso- 



AMPHORIC RESONANCE. 71 

nance is vesiculo-tympanitic above the liquid when 
the latter is sufficient to till a third, a half, or even 
two-thirds of the intra-thoracic space. The sign is 
also obtained over the upper lobe when the lower 
lobe is solidified in the second stage of pneumonia, 
and over the lower lobe when the upper lobe is 
solidified. 

A loaf of bread may be used to illustrate a vesic- 
ulo-tympanitic resonance, as follows : By means of 
a hollow cylinder remove longitudinal sections in 
one-half of the loaf, leaving the crust intact. The 
spaces thus produced yield a tympanitic resonance, 
and the portions which surround these spaces give 
the vesicular resonance. The vesicular and the 
tympanitic quality are thus combined, with eleva- 
tion of pitch and increased intensity ; over the other 
half of the loaf the resonance is purely vesicular. 
Another method of illustrating this sign out of the 
body is to inflate the human lungs, or the lungs of 
the sheep or calf, considerably beyond the limit of 
a normal inspiration. Inflated beyond that limit the 
emphysematous condition is produced, and the reso- 
nance represents that condition. 

5. Amphoric Resonance. 

Resonance is said to be amphoric when it has a 
musical intonation analogous to that produced by 
blowing over the mouth of an empty bottle. An 
amphoric sound is easily illustrated by filliping the 
cheek made tense, the mouth not completely closed, 
and the jaws separated, as is done when the sound 
of a liquid flowing from a bottle is imitated. By 
varying the size of the cavity of the mouth, the am- 



72 PERCUSSION IN DISEASE. 

phoric sound thus produced may be made to vary 
much in pitch. This illustration exemplifies the 
mechanism of the sign in disease. 

The sign represents a pulmonary cavity w^hich is 
generally phthisical. Tije conditions, aside from 
the existence of the cavity, are, rigidit}" of its walls, 
so that they do not collapse, the presence, of course, 
of air within the cavity, and free communications 
with the bronchial tubes. These accessory condi- 
tions are not constant, so that an amphoric resonance 
over a cavity is sometimes found, and other times 
wanting. Directly after having been wanting, it 
may be reproduced if the patient expectorate freely. 

TVhen percussion is made with reference to this 
sign, the mouth of the patient should be open, and 
one or two rather forcible blows are better than a 
series of four or six. The amphoric sound may be 
often distinctly perceived if the ear be brought into 
close proximity to the patient's open mouth, when 
the sign is not appreciable otherwise. It may be 
rendered still more distinct by means of the binaural 
stethoscope, the pectoral extremity being close to 
the mouth of the patient. 

As a cavernous sign the amphoric resonance is 
very reliable ; but it does not invariably denote a 
pulmonary cavity. It is obtained in some cases of 
pneumothorax, the pleural space filled with air form- 
ing a cavity which communicates with the bronchial 
tubes through a perforation of the lung situated above 
the level of the liquid. It is sometimes obtained over 
a solidified portion of lung situated in close proximity 
to a primary bronchus, the resonance being derived 
from the air within the latter. It is occasionally 



CRACKED-METAL RESONANCE, 73 

produced by percussing over the site of the primary 
bronchus in the second stage of pneumonia aiFecting 
an upper lobe. In children, owing to the yielding 
of the costal cartilages, it may even be produced in 
health over a primary bronchus. In all these excep- 
tional instances the associated signs and symptoms 
will prevent the error of attributing the sign to a 
pulmonary cavity. 

This sign is properly a variety of tympanitic reso- 
nance. 

6. Cracked-metal Resonance. 

The name of this sign, expressing an analogy to 
the sound produced by striking a cracked metallic 
vessel, denotes its peculiar character. It may be 
imitated by folding the hands so as to form a cavity 
and striking them upon the knee, in the familiar 
trick of producing in this way a sound as if metal 
coins were between the palms. This illustration, 
also, exemplifies the mechanism of the sign. Like 
the sign last described, it is a variety of tympanitic 
resonance. 

The cracked-metal, like the amphoric, resonance 
represents generally a phthisical cavity. Percussion 
is to be made in the same way as for the production 
of the amphoric resonance, and, like the latter, the 
cracked-metal character is often perceived if the ear 
be brought close to the patient's mouth when other- 
wise it is not appreciable. 

The cracked-metal and the amphoric resonance 
are often associated ; and the statements made with 
respect to the exceptional instances in which the 

7 



74 PERCUSSION IN DISEASE. 

latter is produced, without the existence of a pul- 
monary cavit}', will apply equally to the former. 

In addition to the acoustic phenomena produced 
by percussion with the fingers applied to the chest 
instead of a pleximeter, an abnormal sense of resist- 
ance is felt in certain conditions of disease. In 
health, with a somewhat forcible percussion, the 
walls of the chest are felt to yield in proportion as 
the costal cartilages are flexible. This yielding is 
diminished or ceases w^hen a collection of liquid in 
the pleural cavity, or liquid in the air-vesicles, and 
solidification of lung, ofier a mechanical obstacle 
thereto. An abnormal sense of resistance on per- 
cussion, thus determinable by comparison of the 
two sides of the chest, is a sign representing some 
one of the morbid physical conditions just named. 
This properly belongs among the signs obtained by 
palpation. The sign is to be taken in connection 
with other signs in determining the condition which 
exists in particular cases. 



CHAPTER lY. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — Immediate 
and mediate auscultation — Advantages of the binaural stethoscope — 
Rules to be observed in auscultation— Divisions of the study of auscul- 
tation in health — The normal laryngeal and tracheal respiration — The 
normal vesicular murmur; its distinctive characters, and the variations 
in the different regions on the same side, and in corresponding regions 
on the two sides of the chest — The normal vocal resonance — The 
laryngeal and tracheal voice and whisper — The normal thoracic vocal 
resonance and fremitus ; the distinctive characters of each : the varia- 
tions in different regions on the same side, and in corresponding regions 
on the two sides of the chest — The normal bronchial whisper, v^ith its 
variations in different regions on the same side, and in corresponding 
regions on the two sides of the chest. 

The term auscultation, limited in its application 
to the respiratory system, denotes the act of listen- 
ing to the normal and abnormal sounds produced 
by respiration, voice, and cough. In this and the 
next chapter, the method of exploration thus named 
will be considered in its application to the respira- 
tory system ; it will be considered subsequently as 
applied to sounds relating to the circulatory system. 

The study of auscultatory sounds in health is 
essential as preparatory for the study of auscultation 
in disease. The student must be familiar with the 
normal sounds before undertaking • to become ac- 
quainted with those which represent morbid condi- 
tions. Ample time and attention should be given 
to the study of auscultation in health. The omis- 



76 AUSCULTATION IN HEALTH. 

sion to do this is a frequent cause of difficulty and 
want of success in attaining to a satisfactory proti- 
ciency in physical diagnosis. The practical skill re- 
quired in diagnosis may be obtained in advance by 
devoting sutiicient study to the healthy chest before 
entering on the study of the auscultatory signs of 
disease. Moreover, as will be seen, some of the 
most important of the morbid signs have their 
analogues in certain normal sounds pertaining to the 
respiratory system. 

Auscultation is either immediate or mediate. It 
is immediate when the ear is applied directly to the 
chest, which may be either denuded or covered with 
a cloth or more or less of the clothing. It is mediate 
when the sounds are conducted to the ear by means 
of an instrument called a stethoscope. The student 
should practise both immediate and mediate auscul- 
tation. The direct application of the ear to the 
chest suffices for diagnosis in many cases of disease; 
but there are sometimes objections to this by the 
patient on the score of delicacy, and by the auscul- 
tator on the score of the uncleanliness of the person 
examined. There are certain parts of the chest which 
can onW be explored by the stethoscope, and this 
instrument has the advantage of circumscribing the 
space whence the auscultatory sounds are derived. 
Moreover, by means of the stethoscope which is to 
be preferred over the great variety of instruments 
heretofore in use, the sounds are heard much better 
than by immediate auscultation. 

The stethoscope which is to be preferred conducts 
the sounds into both ears, that is, it it binaural. In 
this consists its great superiority. At the present 



AUSCULTATION IN HEALTH. 



77 



time what is known as Cammann's stethoscope^ 
seems to combine more recommendations than any 
other form of a binaural instrument. (Fig. 8.) The 
conduction into both ears renders the sounds much 
louder and more distinct than when they are heard 
with one ear in either mediate or immediate auscul- 
tation. Another advantage is, the mind is not dis- 
tracted by sounds entering the ear not employed in 
auscultation. The advantages, however, of Cam- 
mann's stethoscope are not appreciated until after 

Fig. 8. 




Cammaun's Stethoscope. 

some practice. At first, a humming sound is heard 
which divides the attention and thus obscures the 
intra-thoracic sounds. After a little practice this 
humming sound is not heeded, and it ceases to be 
any obstacle. Many who use the instrument only 
a few times are dissatisfied with it and discontinue 
its use, when, if they had used it longer, they would 
not have been willing to dispense with it. The 
author's experience with a large number of classes 
in private instruction has been this : at first, most 
members of a class prefer the ear applied directly to 



Invfented by the late Dr. Canimann, of New York. 
7* 



78 AUSCULTATION IN HEALTH. 

the chest; but, before the course of instruction is 
ended, the binaural stethoscope is so much preferred 
that it is difficult to enforce a fair proportion of prac- 
tice in immediate auscultation. 

Another reason for the fact that this stethoscope 
is not sufficiently appreciated in this country is that 
many of the instruments sold are defectively made. 
Unless proper attention has been paid to all the nice 
points of the stethoscope as devised by Cammann, 
an instrument is worthless. An. instrument must 
be very good, or it is without value. The knobs 

Fig. 9. 




totlioscope. 



which are to enter the ears must be of the right 
size ; if they enter too far they occasion pain. The 
curves at the aural extremity must be such that the 
aperture is in the direction of the meatus of the 
ear. The flexible tubes must not be stiff, and their 
movements must be noiseless. All the tubes must 
be unobstructed, for it is the air within the tubes 
which chiefly conducts the sounds. In the use of 
the instrument it should be applied to the chest 
without any intervening clothing.^ 

^ The stethoscopes made by Tiemann & Co. and Ford & Co. are 
reliable. 



AUSCULTATION IN HEALTH. 79 

The stethoscope known as Allison's differential 
stethoscope {vide Fig. 9), is binaural with two pectoral 
extremities. With this instrument intra-thoracic 
sounds are received simultaneously from different 
situations. This stethoscope is only useful for the 
comparison of sounds as regards the relative time of 
their occurrence. The advantage of the better con- 
duction of sounds when they are received into both 
ears is, of course, lost. In other respects than the 
comparison as to the occurrence of sounds synchro- 
nously, or otherwise, the differential stethoscope has 
no advantage. A little reflection and practice will 
suffice to show that to compare different sounds in 
respect of pitch and quality, it is better to listen to 
them successively than simultaneously. 

The rules to be observed in the practice of auscul- 
tation, in health and disease, may be here introduced. 

In auscultation, as in percussion, corresponding 
situations on the two sides of the chest are to be 
explored successively, and compared. When the 
stethoscope is used, the pectoral extremity must 
be applied on each side with the same degree of 
pressure; this is especially essential in the com- 
parison of vocal sounds. In immediate ausculta- 
tion, the ear is to be applied with a certain degree 
of force, and a thin layer of clothing does not inter- 
fere materially with the perception of auscultatory 
sounds. The ear not applied to the chest may or 
may not be closed by the finger in listening to the 
respiratory sounds; it should be closed in listening 
to the vocal sounds, in order to prevent confusion 
from attention to the voice from the patient's mouth. 
In immediate auscultation, whenever practised, the 



80 AUSCULTATION IN HEALTH. 

auscultator should take a position which will not in- 
terfere with the sense of hearing, and not occasion a 
feeling of discomfort. These difficulties are in the 
way of auscultating with the body bent forward; 
the sense of hearing is dulled by the detention of 
blood in the head, and the position cannot be main- 
tained without discomfort. The person examined, 
if practicable, should be sitting, and the position for 
the auscultator is that of kneeling on one knee, and 
lowering, if necessary, the body, so that the head 
may be kept upright. These points are less im- 
portant if the binaural stethoscope be used. 

When listening to respiratory sounds, it is gener- 
ally desirable that the person examined should 
breathe with somewhat greater force than in ordi- 
nary breathing; but it is important that the normal 
rhythm of respiration should be unchanged. Per- 
sons when requested to breathe with increased force 
are apt to err in breathing violentl}^, and sometimes 
too slowly. The readiest mode of obtaining what 
is desired, is for the examiner to illustrate it by his 
own breathing. A complete expiration is important 
in order to secure a satisfactory inspiration. It 
should, therefore, be made clear by explanation and 
illustration, that each expiration should be finished 
before the following inspiration. Breathing through 
Dr. E. Holden's " Resonator," a flexible tube of con- 
siderable size, with a mouth-piece, secures the re- 
quisite force of the respiratory acts, and is in this 
way useful. (Fig. 10.) 

The ability to abstract the mind from thoughts 
and other sounds than those to which the attention 



AUSCULTATION IN HEALTH. 81 

is to be directed, is essential to success in ausculta- 
tion. All persons do not possess equally this ability, 
and herein is an explanation in part of the fact that 
all are not alike successful. To develop and culti- 
vate by practice the power of concentration, is an 
object which the student should keep in view. 
Generally, at first, complete stillness in the room is 



Fig. 10. 




\ 1 



Holden's Resonator. 



indispensable for the study of auscultatory sounds ; 
with practice, however, in concentrating the atten- 
tion, this becomes less and less essential. 

The study of auscultation in health embraces the 
following : 

1. The sounds produced by respiration as heard 
over the larynx and trachea, or the normal laryngeal 
and tracheal respiration. 

2. The sounds heard over the chest in the acts 
of respiration. These sounds, coming chiefly from 
the air-vesicles, constitute what is called the normal 
vesicular murmur. 

3. The resonance heard over the chest, and the 
vibration or thrill produced by the loud voice, or 
the normal vocal resonance and fremitus. 



82 AUSCULTATION IN HEALTH. 

4. The sounds heard over the chest with the 
whispered voice, or, inasmuch as these sounds are 
conducted chiefly by the air in the bronchial tubes, 
the normal bronchial whisper. 

These four normal signs will be considered in the 
foregoing order. 

Normal Laryngeal and Tracheal Respiration. 

For all practical purposes the laryngeal and the 
tracheal respiration may be considered to be iden- 
tical, that is, the shades of diflference between the 
sounds in these two situations are not of importance 
as regards the application to physical diagnosis. 
The laryngeal respiration is more readily studied 
than the tracheal, and for the study of both the 
stethoscope is necessary. 

Applying the stethoscope over the side of the 
larynx, the person examined breathing with some 
increase of force, but without any alteration in 
rhythm, a sound is heard with each of the two acts 
of respiration. The inspiratory and the expiratory 
sound, studied separately and contrasted with each 
other, have the following characters relating to in- 
tensity, pitch, quality, duration, and rhythm: The 
inspiratory sound is of variable intensity. In ordi- 
nary breathing it varies much in different persons, 
and in different acts of breathing in the same person. 
It is always considerably intense in forced breathing. 
The pitch is high when compared with the inspira- 
tory sound as heard over the chest. The quality of 
the sound is well defined by the word tubular; the 



NORMAL LARYNGEAL RESPIRATION. 83 

sound at once suggests a current of air through a 
tube. The duration of the- sound is from the begin- 
ning to nearly, not quite, the end of the inspiratory 
act. The characters of the inspiratory sound, thus, 
are more or less intensity, a high pitch, a tubular 
quality, and a duration a little less than that of the 
act of inspiration. 

An expiratory sound is always heard with forced 
breathing. As regards duration, it is as long as, or 
longer than, the sound of inspiration. In general it 
is more intense than the sound of inspiration.' The 
pitch is higher than that of the inspiratory sound. 
The quality is the same as that of the inspiratory 
sound, namely, tubular. 

Repeating the characters distinctive of the normal 
laryngeal respiration, they are as follows: The in- 
spiratory sound is of variable intensity, high in 
pitch, and tubular in quality. The expiratory sound 
is as long as, or longer than, the inspiratory sound ; 
it is higher in pitch, and usually more intense. 
Owing to the inspiratory sound not continuing 
quite to the end of the inspiratory act, there is a 
very short interval between the two sounds. In 
this latter point consists the only variation between 
the rhythm of the acts of breathing and that of the 
sounds. 

The foregoing characters should not only be 
verified by the student, but he should become so 
familiar with them by practice that it requires no 
effort of the mind to recollect them. It will be seen 
hereafter that these characters of the normal laryn- 
geal respiration are precisely those which distinguish 



84 AUSCULTATION IN HEALTH. 

an important morbid physical sign, namely, the bron- 
chial or tubular respiration. 

Normal Vesicular Murmur. 

This is the name usually given to the respiratory 
sounds heard over the diflerent regions of the chest. 
These sounds should be studied with the ear applied 
directly to the chest (immediate auscultation), as 
well as with the stethoscope. In commencing the 
study; the middle of the anterior surface of the chest 
on the right side, to avoid the sounds of the heart, 
or still better, the posterior aspect below the scapula 
on either side, should be selected. The person ex- 
amined should breathe somewhat more forcibly than 
in ordinary breathing, but not violently nor quickly, 
nor too slowly, the normal rhythm being unchanged. 
Children are better than adults for this study, owing 
to the greater intensity of the murmur in early life. 

The characters which belong to the inspiratory 
and the expiratory sound in the normal vesicular 
murmur are as follows : The inspiratory sound is of 
variable intensity. There is a wide variation in dif- 
ferent healthy persons. In some persons it is so 
feeble as scarcely to be appreciable even with the 
binaural stethoscope. The pitch of the sound, com- 
pared with the inspiratory sound in the normal 
laryngeal or tracheal respiration, is notably low. 
The quality of the sound is peculiar; no distinct 
idea of the quality can be formed by any comparison. 
The name used to designate the quality is vesicular, 
this name only denoting that the air-vesicles are in 
some way concerned in the production of the sound. 
This vesicular quality must be impressed upon the 



NORMAL VESICULAK MURMUR. 85 

perception and memory by direct observation. The 
duration of the inspiratory sound is from the begin- 
ning to the end of the inspiratory act. 

An expiratory sound is not always, although gener- 
ally, appreciable. It is much less intense than the 
sound of inspiration. It is notably lower in pitch 
than the sound of inspiration. The quality of the 
sound is neither vesicular nor tubular. It may be 
called simply a blowing sound, and may be imitated 
by blowing with the mouth partially opened. The 
duration is much shorter than that of the inspira- 
tory sound. 

The characters, thus, which distinguish the normal 
vesicular murmur are, an inspiratory sound variable 
in intensity, low in pitch, and vesicular in quality ; 
an expiratory sound less intense than the inspira- 
tory, still lower in pitch, non-vesicular and non- 
tubular, or simply blowing ; the inspiratory sound 
continuing from the beginning to the end of the in- 
spiratory act, and the expiratory sound beginning 
with the expiratory act but ending before this act is 
completed, its duration, relatively to the inspiratory 
sound, being variable, but averaging about a fifth. 
The inspiratory sound continuing to the end of in- 
spiration, and the expiratory sound beginning with 
the act of expiration, it follows that there is no in- 
terval between the two sounds. It is to be remarked 
that an interval is not infrequently produced by the 
person examined holding the breath after inspira- 
tion is completed. This variation in the rhythm of 
the acts, of course, produces a corresponding varia- 
tion in sounds of breathing. 

The characters of the normal vesicular respiration 



86 AUSCULTATION IN HEALTH. 

may be studied by inflating the lungs removed from 
the human cadaver, or from the sheep or calf, and 
applying the binaural stethoscope directly upon the 
pulmonary surface. In this experiment the vesic- 
cular quality is strongly marked. In the same waj^ 
the tracheal respiration may be studied and its 
characters contrasted with those of the vesicular 
respiration. It is recommended to the student to 
resort to this readily available method to study the 
normal respiratory signs. 

Having become familiar with the characters of 
the normal vesicular respiration as compared with 
those of the normal laryngeal or tracheal respira- 
tion, the student may then proceed to study the 
former in the different regions of the chest. The 
murmur will be found to present variations in the 
different regions on the same side, and in the corre- 
sponding regions on the two sides of the chest. 
The variations, within the range of health, in the 
latter are especially important. The following ac- 
count of the murmur in the different regions 
embodies the results of the analysis of a series of 
recorded examinations of healthy persons.^ 

Right and Left Infra-clavicular Region. — The mur- 
mur in this region, on either side, differs more or 
less from the murmur as heard in the anterior re- 
gions below, or in the infra-scapular region. The 
vesicular quality in the inspiration is less marked. 
The pitch is higher. The expiratory sound is longer, 
less feeble, and higher in pitch. The difference be- 

1 Vide Prize Essay, Transact. Am. Med. Association, Vol. V., 
1852. 



NORMAL VESICULAR MURMUR. 87 

tween the two sides in this region is especially im- 
portant with reference to diagnosis. The intensity 
of the inspiratory sound is almost invariably greater 
on the left side. Its vesicular quality is more 
marked, and the pitch is lower. Per contra, the 
inspiratory sound on the right side, in this region, 
is less intense, less vesicular, and higher in pitch 
than the inspiratory sound on the left side. In 
forced breathing the intensity of the murmur is in- 
creased more on the left than on the right side. 
The expiratory sound is sometimes wanting on the 
left, when it is heard on the right side. On the 
. right side, the expiratory sound is longer than on 
the left side. It may be prolonged on the right 
side to nearly or quite the length of the inspiratory 
sound. Sometimes on the right side the pitch of the 
expiratory is higher than that of the inspiratory on 
the same side, and it may have a tubular quality. 
A rare peculiarity is a prolonged, high, tubular ex- 
piratory sound on both sides, analogous to the 
laryngeal or tracheal expiration. When this is the 
case, the pitch of the expiratory sound is higher on 
the left than on the right side. 

These several modifications of the respiratory 
murmur in the infra-clavicular region are marked 
in proportion as the sounds are studied near the 
sternum, that is, over the site of the primary 
bronchi. The respiratory murmur in this situa- 
tion has been called the normal bronchial respira- 
tion, from its resemblance to the morbid sign so 
named. It may be more properly called a vesiculo- 
tubular, or the normal broncho-vesicular respira- 
tion, the characters being those of the morbid sign 



05 AUSCULTATION IN HEALTH. 

which, under the latter name, will be described in 
the next chapter. 

In the diagnosis of diseases, especially of phthisis, 
due allowance must be made for the points of dis- 
parity which exist normally between the two sides 
of the chest in the infra-clavicular region. Without 
a practical knowledge of these points of disparity, 
error in diagnosis can hardly be avoided. 

Bight and Left Scapular Begion. — As compared 
with the infra-clavicular region, the respiratory 
murmur heard over the scapula on either side is 
feeble, and the vesicular quality is less marked. 
The inspiratory sound is generally weaker and the 
pitch higher on the right than on the left side. 
The expiratory sound is more constantly heard on 
the right than on the left side. It may be prolonged 
on the right side, and is sometimes higher in pitch 
than the inspiratory sound. Compared with the 
left side, the murmur on the right, in this region, 
thus may have vesiculo-tubular or broncho-vesicular 
characters more or less marked. 

Bight and Left Inter-scapular Begion. — In the upper 
and middle portions of this region, the normal char- 
acters are the same as in the sterno-clavicular portion 
of the infra-clavicular region. The same points of 
disparity between the two sides are more or less 
marked here as they are anteriorly over the site of 
the primary bronchi. 

Bight and Left Infra-scapular Begion. — The inten- 
sity of the murmur is greater than over the scapular 
region. In most persons there is no notable disparity 
between the two sides ; when a disparity exists, the 
intensity is greater and the pitch lower on the left 



NORMAL VOCAL RESONANCE. 89 

side. A prolonged, high-pitched, bronchial expi- 
ratory sound is sometimes transmitted below the 
scapula on the right side. 

Right and Left Mammary and Infra-mammary Re- 
gions. — The inspiratory sound in these regions is less 
intense than in the infra-clavicular region ; the vesic- 
ular quality is more marked, and the pitch is lower. 
An expiratory sound is often wanting. 

Right and Left Axillary and Infra-axillary Regions. 
— The inspiratory sound in these regions is as in- 
tense as in any portion of the chest. The intensity 
is less in the infra-axillary than in the axillary re- 
gion, and the pitch is lower. In some persons the 
murmur on the two sides presents no disparity, but 
in other persons the vesicular quality is somewhat 
more marked and the pitch is lower on the left than 
on the right side. An expiratory sound is oftener 
heard than in the mammary and infra-mammary 
regions. 

Normal Vocal Resonance. 

Laryngeal and Tracheal Voice. — It will prepare the 
student for the appreciation of the distinctive char- 
acters of the morbid signs pertaining to the voice, 
to study the vocal signs over the larynx and trachea. 
Applying the stethoscope either over the broad sur- 
face of the thyroid cartilage, or just above the sternal 
notch, and requesting the person examined to count 
with a moderate intensity of voice, the auscultator 
perceives a strong resonance, with a sensation of 
concussion or shock, and a sense of vibration, thrill, 
or fremitus. The voice seems to be concentrated 
and hear the ear. Sometimes the articulated words 
8* 



90 AUSCULTATION IN HEALTH. 

are transmitted so as to be heard more or less dis- 
tinctly. The laryngeal or tracheal voice thus (laryn- 
gophony, tracheophony) embraces different elements, 
namely, 1st, the vocal resonance; 2d, the concen- 
tration and nearness to the ear ; 3d, the vibration, 
thrill, or fremitus; and 4th, the transmission of the 
speech, the latter corresponding to pectoriloquy. 
These different elements will be found to enter into 
the distinctive characters of morbid vocal signs. 

The sounds heard over the larynx and trachea 
when words are spoken in a whisper should be 
studied, inasmuch as important morbid signs relate 
to the whispered voice. Whispered words occasion 
little or no shock or thrill, but an intense, high- 
pitched tubular sound, with a sensation as if a cur- 
rent of air were directed into the ear through the 
stethoscope. This sound corresponds to the sound 
of expiration in laryngeal or tracheal respiration ; 
the two sounds are, in fact, identical if, as is the 
case with some exceptions, the person whisper with 
the expiratory breath. Articulated words are 
transmitted with more or less distinctness, thus 
corresponding with the morbid sign called whisper- 
ing pectoriloquy. 

Normal Thoracic Vocal Resonance and Fremitus. — 
The vocal resonance over the chest is to be studied 
both by means of the stethoscope and by immediate 
auscultation. When the latter is employed the ear 
not applied to the chest should be closed in order 
to exclude the entrance of sound from the mouth of 
the person examined. When the stethoscope is em- 
ployed, care must be taken, in making a comparison 
between the two sides of the chest, or between dif- 



NORMAL VOCAL RESONANCE. 91 

ferent regions on the same side, that the pectoral 
extremity of the instrument be pressed with an 
equal amount of force against the chest. The in- 
tensity with which the vocal resonance is transmitted 
is much affected by the degree of pressure with the 
stethoscope. 

The situations in which the student should com- 
mence the study of the normal vocal resonance are 
those selected for beginning the study of the normal 
vesicular murmur, namely, the middle of the anterior 
aspect of the chest on the right side, and below the 
scapula behind. 

With the stethoscope or the ear directly applied 
in the situations just named, the person examined 
should be requested to count one, two, three, in a 
uniform tone, and with moderate force. The ex- 
aminer should himself pronounce these numerals, 
in order to show the manner of counting. This is 
far better than asking a question and studying the 
resonance during the answer of the person examined. 
The objection to the latter mode is, the attention of 
the examiner is divided between the characters of 
the thoracic resonance and the idea conveyed by 
the answer. The characters of the vocal resonance 
in these situations are as follows : 

The voice is heard with an intensity which varies 
very much in different persons ; in some the reso- 
nance is feeble, and it may be almost inappreciable, 
while in others it is quite intense. The intensity 
depends greatly on the loudness and lowness in 
pitch of the voice of the person examined. The 
resonance is notably weaker in women than in men. 
It is rarely attended with a sense of concussion or 



92 AUSCULTATION IN HEALTH. 

shock. It is diffused ; that is, it does not seem to 
be concentrated like the tracheal or laryngeal vocal 
resonance. It evidently comes from a certain dis- 
tance; that is, the sound does not seem to be 
near the ear. Impression of the distance of the 
sound is highly distinctive of the normal reson- 
ance as compared with a morbid vocal sign (bron- 
chophony). The resonance is accompanied by a 
sense of vibration, thrill, or fremitus, the intensity 
of which, like the resonance, varies much in dif- 
ferent persons. This fremitus is properly not an 
acoustic but a tactile sign. The normal vocal fre- 
mitus, together with its abnormal modifications, be- 
long to the method of physical exploration called 
palpation. It is, however, appreciated by the ear as 
well as by the touch, and may be studied in the 
practice of auscultation. The student should prac- 
tically distinguish from each other, and study sepa- 
rately, the vocal resonance and vocal fremitus. 

From the foregoing characters the normal vocal 
resonance may be defined as, diffused, distant, vari- 
able in intensity, and accompanied with more or less 
vibration, thrill, or fremitus. 

Having become practically familiar with these 
characters of the normal vocal resonance in the 
situations in which they are first to be studied, the 
next object of study relates to the normal variations 
in the different regions on the same side of the 
chest, and in corresponding regions on the two 
sides. In giving an account of these variations, 
based on a series of recorded examinations in 
healthy persons, the different regions will be con- 



NORMAL VOCAL RESONANCE. 93 

sidered in the same order as in the study of the vari- 
tions of the respiratory sounds [vide p. 86 et seq.). 

Infra-clavicular Begion. — The vocal resonance in 
this region on either side is more intense than in 
the anterior regions below, the intensity, however, 
in diiFerent persons being very variable. Irrespec- 
tive of intensity, it is less diffused nearer the ear, 
and the pitch is somewhat higher. These latter 
variations are marked chiefly in the stern o-clavic- 
ular extremity of the region, that is, over the site of 
the primary bronchi. In some persons the concen- 
tration, nearness to the ear and elevation of pitch, 
especially on the right side, are such as to approxi- 
mate the normal resonance to the morbid sign called 
bronchophony. The characters of this sign will be 
considered in the next chapter, but it is important 
to know that exceptionally these characters may be, 
in a measure, illustrated in health in the infra-clavic- 
ular region. The resonance may then be termed 
normal bronchophony. 

A comparison of the resonance in the region on 
the right side and on the left side always shows a 
disparity. The resonance on the right side is in- 
variably greater. The degree of difference between 
the two sides varies in different persons. The reso- 
nance may be more or less marked on the right and 
nearly wanting on the left side. Allowance is to 
be made for the points of normal disparity between 
the two sides in the diagnosis of disease ; hence the 
student must become practically familiar with them. 

The vocal vibration or fremitus varies fully as 
much as the vocal resonance in different persons. 
Its intensity is not always proportionate to that of 



94 AUSCULTATION IN HEALTH. 

the resonance ; that is, the resonance may be com- 
paratively weak when the fremitus is strong, and 
vice versa. The fremitus, like the resonance, is 
always greater on the right than on the left side, 
the disparity, like that of the resonance, varying 
considerably in different persons. 

Scapular Region. — The resonance in this region is 
notabl}^ less intense than in the infra-clavicular re- 
gion. It is also more diffused and distant. The 
intensity is always greater on the right side. These 
statements are alike applicable to the vocal fremitus. 

Inter-scapular Region. — The intensity of the reso- 
nance here is nearly or quite as great as in the 
steruo-clavicular extremity of the infra-clavicular 
region. The resonance has in some persons in this 
region the characters of bronchophony. The in- 
tensity is always greater on the right side. The 
fremitus is more or less marked, and always more 
marked on the right than on the left side. 

Infra- scapular Region. — As a rule, the resonance 
in this region is stronger than over the scapula. It 
is always characterized by diffusion and distance. 
As in all the regions, it varies much in different 
persons, and is stronger on the right than on the 
left side. These statements are also applicable to 
fremitus. 

3Ianimary and Infra-mammary Regions. — The reso- 
nance is notably less than at the summit of the chest. 
The characters of bronchophony are never present. 
The intensity is greater on the right side. The 
same is true of fremitus. 

Axillary and Infra-axillary Regions. — The resonance 
in these regions, and especially in the axillary region, 



NORMAL BRONCHIAL WHISPER. 95 

is greater than over the mammary and infra-mam- 
mary regions. It is, of course, stronger on the right 
side, Tlie characters as contrasted with those of 
bronchophony, namely, distance and diifasion, are 
marked. Fremitus is more or less marked, and, of 
course, more marked on the right than on the left 
side. 

Normal Broncliial Whisper. 

Prior to the publication of the author's work on 
the " Physical Exploration of the Chest," in 1856, 
signs in health and disease relating to the whispered 
voice had received but little attention. In that work, 
and more fully in the second edition, published in 
1866, a series of signs accompanying whispered 
words were described and named. As a point of 
departure for the study of the morbid signs thus 
obtained, of course the signs in health must first be 
studied. The sounds which are heard over different 
parts of the chest in health I have embraced under 
the name, the normal bronchial whisper. The per- 
tinency of this name is derived from the fact that the 
conduction of the sound produced by the whispered 
voice must be chiefly by the air contained in the 
bronchial tubes. The sound heard over the trachea 
and larynx may be distinguished as the laryngeal or 
tracheal whisper, the characters of which have been 
already stated {vide page 90). 

It will facilitate the study of the normal bronchial 
whisper, as well as of the morbid signs, to consider 
that the characters of the sounds produced with the 
whispered voice are identical with those produced 
by the act of expiration in all respects save intensity. 



yt> AUSCULTATION IN HEALTH. 

Whispered words are produced, as a rule, by an act 
of expiration, the sounds being more intense gen- 
erally than those which accompany even forced 
breathing. Curiously enough, there are exceptions 
to this rule. Some persons insist upon whispering 
with the act of inspiration, and there are some per- 
sons who have never acquired the ability to whisper. 
It will be at once evident that the pitch and quality 
of sounds produced by whispered words with the 
act of expiration, must be the same as those of the 
sounds of expiration in breathing. 

Selecting for the study of the normal bronchial 
whisper the same situations as in commencing the 
study of the normal respiratory murmur, and the 
normal vocal resonance, namely, the middle of the 
chest in front, on the right side, and the infra- 
scapular region behind, with the whispered voice in 
these situations is heard, in most persons, a feeble, 
low-pitched blowing sound, these characters corre- 
sponding to those of the expiratory sound in forced 
breathing. The normal bronchial whisper in these 
situations is not in all persons appreciable. 

In the infra-clavicular region, the bronchial whisper 
is heard, with variable intensity, in most persons. It 
is somewhat higher in pitch than the whisper below 
this region. It is louder and higher in the sterno- 
clavicular than in the acromial extremity. In the 
former situation it has not infrequently a tubular 
quality. It is louder on the right than on the left 
side of the chest. It is sometimes heard on the right 
when it is inappreciable on the left side. When 
heard on both sides the pitch of the sound is higher 
on the left than on the right side. It will be ob- 



NORMAL BRONCHIAL WHISPER. 97 

served that these variations correspond to those of 
the sound with expiration in the infra-clavicular 
region (vide page 86). Occasionally whispered words 
are partly transmitted, constituting incomplete whis- 
pering pectoriloquy. 

In the scapular region the bronchial whisper is 
not infrequently wanting. It may be present on the 
right and not on the left side, and if present on both 
sides, it is always louder on the right side. 

In the inter-scapular region, as a rule, it is nearly 
or quite as marked as over the site of the primary 
bronchi in front. The pitch is more or less high, 
and has a tubular quality. It is louder on the right 
and higher in pitch on the left side, and in this 
situation there may be incomplete pectoriloquy. 

In the infra-scapular region, it is not infrequently 
wanting. When present it is generally feeble, the 
pitch being low and the quality non-tubular, or 
blowing. It is oftener wanting on the left than on 
the right side, and, if present on both sides, it is 
louder on the right side. 

In the mammary and infra-mammary regions it is 
not infrequently wanting, and the statements just 
made with reference to the infra-scapular region are 
alike applicable to these, as, also, to the axillary and 
infra-axillary regions. 



CHAPTER V. 

AUSCULTATION IN DISEASE. 

The respiratory signs of Disease : — Abnormal modifications of the normal 
respiratory sounds: — Increased vesicular murmur — Diminished vesic- 
ular murmur — Suppressed respiratory sound — Bronchial or tubular 
respiration — Broncho-vesicular respiration — Cavernous respiration — 
Broncho-cavernous respiration — Vesiculo cavernous respiration — 
Amphoric respiration — Shortened inspiration — Prolonged expiration — 
Interrupted respiration. Adventitious respiratory sounds or rales. 
Laryngeal or tracheal rales — Moist bronchial rales, coarse, fine, and 
subcrepitant — Vesicular or crepitant rule — Cavernous or gurgling rale 
— Pleural friction rules, metallic tinkling and splashing — Indeterminate 
rrUes. The vocal signs of disease: Bronchophony — Whispering bron- 
chophony — ^gopbony — Increased vocal resonance — Increased bron- 
chial whisper — Cavernous whisper — Pectoriloquy — Amphoric voice or 
echo — Diminished and suppressed vocal resonance- — Diminished and 
suppressed vocal fremitus — Metallic tinkling. Signs obtained by acts 
of coughing or tussive sounds. 

The importance of becoming perfectly familiar 
with the signs of health before entering upon the 
study of morbid signs, cannot be too strongly en- 
forced. The auscultatory signs of disease, which 
are to be considered in this chapter, should not be 
studied until the student has made himself complete 
master of all the characters belonging to the normal 
signs obtained by auscultation. 

Auscultation in disease embraces the signs pro- 
duced by respiration, by the voice, and by acts of 
coughing. The respiratory signs Avill be first con- 
sidered. 



MODIFICATIONS OF NORMAL SOUNDS. 99 



The Respiratory Signs of Disease. 

The morbid signs produced by respiration may be 
classified as follows : 1st. Those which are abnormal 
modifications of the normal respiratory sounds. 2d. 
Those which have no analogues in health, being 
entirely new or adventitious sounds. The latter are 
usually embraced under the name ra;les. 

Abnormal Modifications of the Normal Respiratory 
Sounds. 

In order to appreciate the distinctive characters 
of the signs embraced in this class, the characters 
which distinguish the normal vesicular murmur must 
be kept in mind. The abnormal modifications which 
characterize these morbid signs relate to intensity, 
pitch, and quality of sound, together with certain 
alterations in rhythm. Twelve signs are included 
under this heading, namely: 1. Increased vesicular 
murmur; 2. Diminished vesicular murmur; 3. Sup- 
pression of respiratory sound; 4. Bronchial or tubu- 
lar respiration ; 5. Broncho-vesicular respiration; 6. 
Cavernous respiration; 7. Broncho-cavernous respi- 
ration; 8. Yesiculo-cavernous respiration; 9. Am- 
phoric respiration; 10. Shortened inspiration; 11. 
Prolonged expiration; and, 12. Interrupted inspi- 
ration. 

These signs are to be studied, first, with reference 
to their distinctive characters severally, each being 
contrasted, as respects these characters, with the 
other morbid respiratory signs as well as with the 
normal vesicular murmur; and, second, with refer- 



100 AUSCULTATION IN DISEASE. 

ence to the morbid physical conditions which they 
severall}?' represent, that is, the diagnostic signifi- 
cance which belongs to each. 

Increased Vesicular Murmur. — This sign has but a 
single distinctive character, namely, increase of in- 
tensity. The murmur is abnormally loud, the char- 
acters of the normal vesicular murmur being in other 
respects not materially changed, that is, the pitch is 
low and the quality vesicular as in health. Now, it 
has been seen {vide page 85) that the intensity of the 
healthy murmur varies much in different persons; 
there is no ideal standard of normal intensity by 
reference to which an abnormal increase is to be 
determined. Yet the increase under certain condi- 
tions of disease is such that the fact is sufficiently 
evident. It occurs on the healthy side of the chest 
when the respiratory function on the other side is 
annulled or much compromised by disease. This 
takes place in cases of pleurisy with large effusion, 
pneumonia, especially if more than one lobe be af- 
fected, obstruction of one of the primary bronchi, 
and pneumothorax. The sign does not possess 
great diagnostic importance inasmuch as the nature 
and extent of the disease are ascertained by the signs 
obtained on the affected side. 

The sign has been called supplementary and puerile 
respiration. 

If the murmur be much intensified, it may possibly 
be mistaken for other morbid signs, namely, bron- 
chial or broncho-vesicular respiration. This error, 
however, can never be made if the distinctive char- 
acters of these signs relating to pitch and quality 
have been correctly studied. 



MODIFICATIONS OF NORMAL SOUNDS. 101 

Diminished Vesicular Murmur. — The intensity of 
the vesicular murmur may be on the one hand di- 
minished when it is evident that in other respects 
there is no material change, and the murmur, on 
the other hand, may become so feeble that characters 
aside from the intensity are not determinable. From 
the latter fact it follows that the murmur must some- 
times be considered as only weakened, when, were 
the diminished intensity not as great, morbid changes 
in pitch and quality might be appreciable. 

The murmur is more or less weakened in cases of 
dilatation of the air-cells, or vesicular emphysema, 
the sign, in these cases, being often accompanied by 
changes in rhythm, namely, a shortened inspiration 
and a prolonged expiration. Simple weakness of 
the murmur may also be incident to partial block- 
ing of the air-vesicles with blood or serum in cases 
of pulmonary extravasation and oedema. A defi- 
cient expansion of the chest, either on one side or 
on both sides, occasions weakness of the respiratory 
murmur. Deficient expansion of one side, or of 
both sides, may be caused by paralysis, bilateral, 
or unilateral, of the costal muscles. A similar effect 
is caused by paralysis of the diaphragm. The in- 
complete descent of the diaphragm from pain, as in 
peritonitis, or from mechanical obstacles, as in peri- 
toneal dropsy, pregnancy, and abdominal tumors, 
weakens the respiratory murmur, the increased ac- 
tion of the costal muscles not being fully compensa- 
tory. Unilateral deficiency of expansion of the 
chest is caused by pain in intercostal neuralgia, 
pleurodynia, acute pleurisy, and pneumonia; it is 
also caused by the presence of a stratum of liquid, 
9* 



102 AUSCULTATION IN DISEASE. 

air, or a thick laj^er of lymph between the lung and 
the chest- wall in pleurisy, hydrothorax, and pneu- 
mothorax. Swelling of the bronchial mucous mem- 
brane in bronchitis affecting the larger tubes, must 
diminish somewhat the intensity of the murmur. 
In primary bronchitis the murmur is diminished on 
both sides. In bronchitis affecting the smaller tubes 
the murmur is greatly diminished, if not suppressed, 
on both sides. Incomplete obstruction of bronchial 
tubes from the presence of mucus, serum, blood, or 
pus, has this effect over an area corresponding to 
the size of the tubes obstructed. Spasm of the 
bronchial muscular fibres in paroxysms of asthma, 
diminishes, if it do not suppress, murmur on both 
sides. Another cause of diminution, unilateral, or 
within a limited space on one side, is the pressure 
of a tumor pressing on bronchial tubes, as in cases 
of aneurism. A permanent contraction or stricture 
of bronchial tubes is another cause. Not infre- 
quently the pressure of an aneurismal tumor or an 
enlarged bronchial gland on a primary bronchus, 
occasions notable weakness of the murmur over the 
whole of one side ; and the pressure of a tumor on 
the trachea weakens the murmur, more or less, on 
both sides. A foreign body in one of the primary 
bronchi weakens it on one side. Diminution of the 
calibre of the trachea or larynx from morbid growths, 
the presence of foreign bodies, fibrinous exudations, 
accumulations of mucus, submucous infiltration, 
spasms of the laryngeal muscles, and swelling of the 
mucous membrane, weakens, in proportion to the 
amount of obstruction, the murmur on both sides 
without any material change in its quality and pitch. 



MODIFICATIONS OF NORMAL SOUNDS. 103 

Weakened murmur at the summit of the chest, 
without other appreciable abnormal characters, 
occurs in some cases of phthisis, due to obstructed 
bronchial tubes from coexisting circumscribed bron- 
chitis, or to deficient superior costal movements of 
the chest, as well as to the presence of exudation in 
the air-vesicles. 

Diminished intensity of the vesicular murmur is 
thus seen to be a respiratory sign entering into the 
diagnosis of a considerable number of diseases, 
namely, emphysema, paralysis affecting the respira- 
tory muscles, asthma, abdominal affections interfer- 
ing with the diaphragmatic movements, intercostal 
neuralgia, pneumonia, hydrothorax, bronchitis, 
aneurismal and other tumors, permanent constric- 
tion or stricture of bronchial tubes, laryngitis, 
oedema of the glottis, spasm of the glottis, the vari- 
ous lesions which occasion obstruction of the larynx 
or trachea, and phthisis. 

In determining a slight abnormal weakness of the 
respiratory murmur at the summit of the chest on 
the right side, the normal disparity between the two 
sides in this situation is to be borne in mind. The 
vesicular murmur is normally less intense on the 
right than on the left side. 

This sign occurring in so many diseases, it is ob- 
vious that, taken alone, that is, independent of other 
signs, it has not any special diagnostic significance. 
It is, however, often of value in diagnosis, when 
taken in connection with other signs. It is chiefly 
useful when it exists either over the whole or in a 
part of the chest on one side. 

Suppressed Respiratory Sound. — This sign is easily 
defined, namely, absence of all respiratory sound, as 



104 AUSCULTATION IN DISEASE. 

the name signifies. It cannot, of course, have any 
characters relating to intensity, pitch, and quality. 

Suppression of respiratory sound represents the 
same physical conditions as diminished vesicular 
murmur; the physical conditions represented by 
the latter sign, existing in a greater degree, occa- 
sion absence of all sound. It suffices, therefore, to 
recapitulate the various conditions and diseases in 
connection with which the murmur may either be 
diminished or suppressed. Suppression over por- 
tions of the chest may be due to dilatation of the 
air-cells in cases of emphysema. It occurs from the 
exclusion of air from the vesicles by the presence of 
blood and serum in cases of pulmonary extravasa- 
tion and oedema. Respiratory sound is sometimes 
wanting over lung solidified in cases of pneumonia 
and phthisis. Paralysis of the muscles concerned 
in respiration may possibly involve feebleness of the 
respiratory acts sufficiently to render the murmur 
inappreciable. In intercostal neuralgia, pleuro- 
dynia, acute pleurisy, and pneumonia, the move- 
ments of the affected side may be so much restricted 
as to abolish the murmur. In pleurisy with much 
effusion, empyema, hydrothorax, pneumothorax, the 
murmur is suppressed over either a part or the whole 
of the affected side, the extent of the suppression 
corresponding to the quantity of serum, pus, or air 
within the pleural cavity. Swelling of the mucous 
membrane in cases of bronchitis affecting the larger 
bronchial tubes is never sufficient to suppress the 
murmur, but plugging of more or less of the tubes 
with mucus or other morbid products may have this 
effect. In cases of bronchitis, the murmur is some- 



MODIFICATIONS OF NORMAL SOUNDS. 105 

times found to have disappeared over a certain area, 
and to return after an act of expectoration. In 
bronchitis affecting the smaller tubes, suppression 
of the murmur is not infrequent. It occurs from 
spasm of the bronchial muscular Hbres in cases of 
asthma. The pressure of a tumor, morbid growths, 
or deposits from bronchi within the lungs, may 
abolish respiratory sound over a portion of the 
chest, and permanent stricture or obliteration of 
bronchial tubes may have this effect. Respiratory 
sound may be suppressed over the whole of one 
side from the pressure of an aneurismal or some 
other tumor upon one of the primary bronchi. If 
the tumor press upon the trachea, the obstruction 
may be sufficient to suppress the murmur on both 
sides. A foreign body lodged in a primary bron- 
chus may suppress the murmur on one side, and, 
lodged in the larynx or trachea, the murmur may 
be suppressed on both sides. The different affec- 
tions of the larynx and trachea which, in proportion 
to the amount of obstruction, weaken the murmur, 
may render it inappreciable. 

Bronchial or Tubular Respiration. — The analogue of 
this sign is the normal laryngeal or tracheal respi- 
ration {vide page 82). The characters which dis- 
tinguish the latter normal sign from the normal 
vesicular murmur, are those which are distinctive 
of the bronchial or tubular respiration. These char- 
acters, relating to the inspiratory and the expiratory 
sounds, are as follows : The inspiratory sound is of 
variable intensity. Intensity does not enter into the 
distinctive characters of this sign ; the sound may 
be either louder or weaker than the inspiratory 



106 AUSCULTATION IN DISEASE. 

sound in health. The pitch of the inspiratory 
sound is high. The quality is expressed by the 
term tubular; it is like the sound produced by 
blowing through a tube, this quality taking the 
place of that expressed b}^ the term vesicular in the 
normal respiration. The expiratory sound is pro- 
longed; it is as long as, or longer than, the sound 
of expiration, and is usually louder. The pitch is 
still higher than that of the inspiratory sound. The 
quality, like that of the inspiratory sound, is tubular, 
this quality taking the place of the simple blowing 
quality of the expiratory sound in the normal vesic- 
ular murmur. With the normal rhythm of the 
respiratory acts there is a very brief interval be- 
tween the sounds of inspiration and expiration, due 
to the fact that the inspiratory sound ends a little 
before the end of the inspiratory act. 

The morbid physical condition represented by 
this important sign is either complete or consider- 
able solidification of lung. Whenever the chest is 
auscultated over lung solidified, if there be not 
absence of respiratory sound, the sound is tubular. 
This significance renders the sign of diagnostic value 
in the diseases which involve solidification. The 
sign per se denotes simply this morbid physical con- 
dition ; the particular disease which exists is ascer- 
tained by means of the associated signs and the 
symptoms. 

Solidification of lung is incident to several dif- 
ferent diseases. In lobar pneumonia it is due to 
a fibrinous exudation within the air-vesicles. In 
phthisis it is caused by an exudation in the same 
situation. In chronic or fibroid pneumonia the lung 



MODIFICATIONS OF NORMAL SOUNDS. 107 

is solidified by an interstitial growth. The com- 
pression of lung from either pleuritic eifusion, an 
accumulation of air in the pleural cavity, or the 
pressure of a tumor, causes solidification b}^ conden- 
sation. Collapse of pulmonary lobules also solidifies 
by condensation. Coagulation of blood within the 
air-vesicles (hemorrhagic infarctus), and cancerous 
infiltration or growth, are other causes of solidifica- 
tion. In these different affections, if the solidification 
be complete or considerable, this sign is usually 
present ; it is always present if there be not suppres- 
sion of respiratory sound. 

It is sometimes the case that either the inspiratory 
or the expiratory sound is wanting. The characters 
of the sign suffice for its recognition if either the in- 
spiratory or the expiratory sound be alone present; 
the pitch and the quality are distinctive. Both 
sounds are often so intense that they are diffused 
more or less without the limits of the solidified por- 
tion of lung. The expiratory sound, being more 
intense than the inspiratory, is transmitted further 
than the latter. This explains the conjunction some- 
times of a vesicular inspiration with a tubular expi- 
ration; and a cavernous inspiration may be conjoined 
with a tubular expiration, showing the proximity of 
solidified lung in the former case to healthy lung, 
and, in the latter case, to a pulmonary cavity. 

The sound may seem near the ear or to come from 
a certain distance. The latter is appreciable in some 
cases of large pleuritic effusion; the tubular respira- 
tion is more or less distant, and it is sometimes dif- 
fused over the whole of the side which is filled with 
liquid. 



108 AUSCULTATION IN DISEASE. 

Broncho-vesicular Respiration. — This name was in- 
troduced by me, in 1856, to denote the combination, 
in varying proportions, of the characters of the 
bronchial or tubular, and of the normal vesicular 
respiration. The name expresses such a combina- 
tion. It embraces modifications to which have been 
applied the terms, rude, rough, and harsh respiration, 
and those included by German authors under the 
name indeterminate respiratory sounds. 

The sign represents the diflerent degrees of solidi- 
fication of lung, between an amount so slight as to 
occasion only the smallest appreciable modification 
of the respiratory sound, and an amount so great as 
to approxinate closely to the degree giving rise to 
bronchial or tubular respiration. In other words, 
all the gradations of respiratory modifications, caused 
by incomplete or an inconsiderable solidification, 
which fall short of bronchial or tubular respiration, 
are embraced under the name broncho-vesicular. 
The gradations correspond to the amount of solidi- 
fication, that is, they show the solidification to be 
either very slight, slight, moderate, or nearly sufEL- 
cient to be considered as considerable or complete. 
The sign is, therefore, important as evidence, first, 
of the existence of solidification; and, second, of the 
degree of solidification. 

Analyzing this sign, the most distinctive feature 
is the combination of the vesicular and the tubular 
quality in the inspiratory sound. These two quali- 
ties may be combined in variable proportions. The 
pitch of the sound is raised in proportion as the 
tubular predominates over the vesicular quality. 
The expiratory sound is more or less prolonged, 



MODIFICATIONS OF NORMAL SOUNDS. 109 

tubular in quality, and the pitch is raised. The pro- 
longation of this sound, its tubular quality, and the 
highness of pitch, are proportionate to the predom- 
inance of the tubular over the vesicular quality in 
the inspiratory sound. If the solidification of lung 
be slight, the characters of the normal vesicular 
respiration predominate; that is, the inspiratory 
sound has but a small proportion of the tubular 
quality, and is but little raised in pitch, the expira- 
tory sound being not much prolonged, its tubularity 
not marked, the pitch not high. If, on the other 
hand, the solidification of lung be almost enough to 
give a bronchial respiration, the inspiratory sound 
has only a little vesicular quality, the tubular quality 
predominating, the pitch proportionately raised; and 
the expiratory sound is prolonged, tubular, and high, 
nearly to the same extent as in the bronchial respi- 
ration. The less the solidification the more the 
characters of the normal vesicular predominate over 
those of the bronchial respiration, and, "per contra, 
the greater the solidification the more the characters 
of the bronchial predominate over those of the nor- 
mal vesicular respiration. Daily auscultation in a 
case of lobar pneumonia during the stage of resolu- 
tion affords an opportunity to study all the grada- 
tions of this sign. After resolution has made some 
progress the inspiratory sound is no longer purely 
tubular, but the ear appreciates a little admixture 
of the vesicular quality and the pitch is slightly 
lowered. As resolution goes on the vesicular quality 
increases, the pitch is correspondingly lowered, until, 
at length, no tubularity remains, and the pitch be- 
comes normal. Meanwhile, as the vesicular quality 

10 



110 AUSCULTATION IN DISEASE. 

increases in the inspiratory sound, the expiratory 
sound is less and less prolonged, high and tubular, 
until it becomes, as in health, short, low, and 
blowing. 

The broncho-vesicular respiration is an important 
diagnostic sign in all the aifections which involve 
partial solidiiication of lung. In lobar pneumonia, 
as just stated, it denotes the progress made from day 
to daj^ in resolution. It is found also in an earlier 
stage, before the solidification is sufficient to give 
rise to a purely bronchial respiration. It is a valu- 
able sign in phthisis, aftbrding evidence, not only of 
the fact of solidification, but of its degree and extent. 
The signs enter into the diagnosis of interstitial 
pneumonia, hemorrhagic infarctus, condensation of 
lung from the pressure of either liquid, air, or a 
tumor, and from collapse of pulmonary lobules. It 
may be stated with respect to this sign, that it is 
always present if the lung be partially solidified, pro- 
vided there be not either suppression of respiratory 
sound, or such a degree of feebleness that the dis- 
tinctive characters are undeterminable. As with the 
bronchial respiration, so with the broncho-vesicular, 
either the inspiratory or the expiratory sound may 
be wanting. The characters of the sign are then to 
be determined as they are manifested in the sound 
which is present, namely, the combination of the 
vesicular and the tubular quality, with more or less 
elevation of pitch, if only an inspiratory sound may 
be heard, and the amount of prolongation, tubu- 
larity, and elevation of pitch, if there be only an 
expiratory sound. 

In determining the presence of this morbid sign 



MODIFICATIONS OF NORMAL SOUNDS. Ill 

at the summit of the chest on the right side, it is to 
be borne in mind that the respiratory murmur on 
this side has, in health, as compared with the respi- 
ratory murmur at the summit on the left side, more 
or less of the characters of the broncho-vesicular 
respiration [vide IS'ormal Broncho-vesicular Respira- 
tion, page 108). 

Cavernous Respiration. — The modifications which 
constitute the distinctive characters of this sign, are 
produced by the entrance of air into a cavity with 
the act of inspiration, and its exit from the cavity 
with the act of expiration. This passage of air into 
and from a cavity can only take place where the 
walls of the cavity collapse more or less in expira- 
tion and expand in inspiration. Pulmonary cavities 
occur chiefly in cases of phthisis. They occur, but 
with comparative infrequency, as a result of circum- 
scribed abscess and gangrene of lung. 

A well-marked cavernous respiration has char- 
acters which are highly distinctive when this sign is 
contrasted, on the one hand, with either the bron- 
chial or broncho-vesicular respiration, and, on the 
other hand, with the normal vesicular murmur. 
These distinctive characters relate both to the inspi- 
ratory and expiratory sound. The inspiratory souud 
is neither vesicular nor tubular in quality, and the 
pitch is low as compared with the bronchial respira- 
tion. As regards quality, we may say of it, as of 
the expiratory sound in the normal vesicular respi- 
ration, it is simply a blowing sound. The expira- 
tory sound has the same quality as the inspiratory, 
and it is lower in pitch. Its duration is variable. 
The intensity of both the inspiratory and the expi- 



112 AUSCULTATION IN DISEASE. 

ratory sound varies ; intensity does not enter into 
the distinctive characters of this sign more than into 
those of the bronchial and the broncho-vesicular 
respiration. These distinctive characters of the 
cavernous respiration, as regards pitch and quality, 
especially of the expiratory sound, were first pointed 
out by me in 1852.^ Prior to this date the bronchial 
and the cavernous respiration were considered as 
having identical characters, or, at all events, as not 
distinguishable from each other. Following Skoda, 
these two signs are still considered as essentially 
identical by German authors. With a practical 
knowledge of the foregoing characters distinctive of 
the cavernous respiration, there is no difficulty in 
discriminating this sign from the bronchial respira- 
tion. The sign is more likely to be confounded 
with the normal vesicular murmur, inasmuch as it 
differs from the latter only in the absence in the in- 
spiratory sound of the vesicular quality. Against 
this error the student is to be cautioned. It is most 
likely to be made when the inspiratory sound is 
much weakened, and, consequently, the vesicular 
quality less distinctly appreciable than when the 
sound is more or less intense. 

A cavernous respiration is limited to a space more 
or less circumscribed, the area corresponding to the 
site and the size of the cavity. Occurring, for the 
most part, in cases of phthisis, it is much oftener 
found at the summit than elsewhere over the chest. 
It is not constantly found where there is a cavity with 

' Prize Essay on Variations of Pitch in the Sounds obtained by 
Percussion and Auscultation. Transactions of the American 
Medical Association, 1852. 



MODIFICATIONS OF NORMAL SOUNDS. 113 

flaccid walls. It may be temporarily suppressed by 
the presence of liquid within the cavity, and by ob- 
struction of the orifices communicating with bron- 
chial tubes, or of the latter. It may be wanting at 
one moment, and an act of expectoration may cause 
it to reappear. Hence absence of cavity cannot be 
predicated on the absence of the sign at a single ex- 
amination. Moreover, if a cavity be not situated 
near the pulmonary superficies, and solidified lung 
intervene between it and the walls of the chest, the 
cavernous sign may be drowned in a loud bronchial 
respiration. For this reason, while the cavernous 
sign is positive evidence of a cavity, the absence of 
the sign is not proof that a cavity does not exist. 

In some cases of perforation of lung with pneumo- 
thorax, the passage of air to and fro through the per- 
foration may give rise to the cavernous respiration. 
As a rule, however, under these circumstances, an- 
other sign is produced, namely, the amphoric respi- 
ration. 

The cavernous respiration may be reproduced by 
the inflation of lungs after their removal from the 
body, the binaural stethoscope being placed over a 
cavity. This is true, also, of the bronchial and the 
broncho-vesicular respiration. These signs may be 
thus illustrated not infrequently after death from 
phthisis, in lungs in which are cavities together with 
portions completely or moderately solidified. 

The distinctive characters of the cavernous respi- 
ration may also be illustrated by means of a small 
India-rubber balloon with an opening at opposite 
ends. Inflating the balloon through a tube intro- 
duced into one opening produces a sound analogous 
10* 



114 AUSCULTATION IN DISEASE, 

to the cavernous inspiration, and tlie expulsion of 
the air by the elasticity of the balloon produces a 
sound analogous to the cavernous expiration. A 
Davidson's syringe may be used to inflate the 
balloon. The sounds are heard by applying lightly 
to the balloon the binaural stethoscope. This illus- 
tration demonstrates the mechanism of the cavern- 
ous respiration. 

Broncho-cavernous jRespiration. — In this sign, as the 
name denotes, the characters of the bronchial and 
the cavernous respiration are combined. These 
characters may be combined in different ways, as 
well as in variable proportions. If a cavity be situ- 
ated in proximity to solidified lung, the quality and 
pitch of the inspiratory and the expiratory sound 
may show an admixture of the characters of the two 
signs, and to a practised ear the combination is dis- 
tinctly recognizable. This is one of the forms of 
broncho-cavernous respiration ; the sounds are not 
sufficiently high and tubular for bronchial, nor suffi- 
ciently low and blowing for cavernous respiration. 
Another form consists of an inspiratory sound, the 
first part of which is tubular, and the latter part 
cavernous. Examples of this form are not ex- 
tremely infrequent. This form has been recently 
described by Seitz under the name, " metamorphosing 
respiration^' Still another form is a cavernous in- 
spiratory, with a bronchial or tubular expiratory 
sound. In the latter form, the bronchial expiration 
proceeds from solidified kmg situated near the cavity, 
the intensity of the sound being sufiicient to drown 
the cavernous expiration. 

When, as often happens, a cavity is situated in 



MODIFICATIONS OF NORMAL SOUNDS. 115 

close proximity to, or, it may be, surrounded by 
solidified lung, the cavernous and the bronchial 
respiration are, as it were, in juxtaposition, and 
such instances ofier an excellent opportunity to 
study the points distinguishing these signs from 
each other; and, generally, at a short distance the 
normal vesicular murmur may be found, so that 
both morbid signs may be compared with the latter. 
Within a circumscribed area sometimes are exem- 
plified the characters of the normal murmur, and of 
the two morbid signs just mentioned, together with 
those of the broncho-vesicular respiration. 

Vesiculo-cavernous Respiration. — It is sometimes evi- 
dent that the vesicular and the cavernous quality are 
combined in the inspiratory sound. This occurs 
when a cavity is surrounded, not by solidified, but 
by healthy lung. Under these circumstances, over 
the site of the cavity the inspiratory sound may be 
as loud as, or louder than, that around the cavity, 
but the quality is not purely cavernous ; some vesic- 
ular quality is appreciable. A vesiculo-cavernous 
respiration, then, is a cavernous respiration jplus 
some vesicular quality derived from the air-vesicles 
which are proximate to the cavity. This sign is 
corroborated by other associated signs showing the 
existence of a cavity and its localization. 

Amphoric Respiration. — The term amphoric has a 
significance when applied to auscultatory sounds, 
analogous to that which it has in percussion ; it de- 
notes a musical intonation which may be compared 
to the sound produced by blowing upon the open 
mouth of a decanter or phial. Whenever the re- 
spiratory sound has this intonation, it denotes a 



116 AUSCULTATION IN DISEASE. 

space containing air which is not expelled with the 
act of expiration. Air in the pleural cavity, with 
perforation of lung, is the physical condition most 
frequently represented by this sign. It is a valu- 
able diagnostic sign in cases of pneumothorax ; but 
it is not always present in that affection, certain ac- 
cessory conditions being requisite, namely, perfora- 
tion above the level of liquid, and an unobstructed 
communication of the bronchial tubes, through the 
opening, with the pleural space containing air. 
While, therefore, its presence is significant of 
pneumothorax, its absence is by no means sufficient 
to exclude this affection. Not infrequently it is a 
sign of a phthisical cavity with rigid walls which do 
not collapse with the act of expiration. The same 
contingencies affect its production here as in cases 
of pneumothorax. Whenever amphoric respiration 
is present, if pneumothorax be excluded by the ab- 
sence of the other signs which are diagnostic of this 
affection, the sign is proof of the existence of a pul- 
monary cavity, the walls of which are not flaccid. 
The sign then takes the place of the ordinary cav- 
ernous respiration which has been described. 

The amphoric sound may accompany either respi- 
ration or expiration, or both. Amphoric respiration 
may be artificially illustrated by connecting an India- 
rubber bag of considerable size (such as is contained 
within a foot-ball) with a flexible tube, and after 
dilating it with air, inflating it forcibly either by a 
pair of bellows or by the mouth, holding the bag 
close to the ear. The amphoric sound thus pro- 
duced represents the amphoric respiration as a 
sign in pneumothorax. As the sign of a tubercu- 



MODIFICATIONS OF NORMAL SOUNDS. 117 

lou8 cavity it may be illustrated by a similar experi- 
ment, using an India-rubber bag of the size of an 
egg or orange. I have localized a tuberculous 
cavity with rigid walls in the centre of a lobe, by 
inflating artificially phthisical lungs after their re- 
moval from the body. 

Shortened Inspiration. — The inspiratory sound is 
somewhat shortened in bronchial or tubular respira- 
tion. This modification enters into the characters 
of that sign, the quality of the sound being tubular, 
and the pitch high.' The shortening is due to the 
sound ending before the inspiratory act ends; the 
sound is said to be unfinished. Shortening of the 
sound occurs, however, when it is not an element 
in the bronchial respiration. The shortening is 
then due to the sound not beginning with the in- 
spiratory act; this is distinguished as deferred in- 
spiratory sound. A deferred inspiratory sound not 
tubular in quality, but more or less vesicular, and 
not notably raised in pitch, is a sign of pulmonary 
or vesicular emphysema. It is a sign of value in 
connection wdth the diagnosis of that disease. 

The student should note the distinctions just 
stated which relate to pitch and quality. Suppose 
an inspiratory sound to be present without an ex- 
piratory sound; if the sound be shortened at the 
end of the inspiration, the pitch high, and the 
quality tubular, it is bronchial respiration, denoting 
complete or considerable solidification of lung, but 
if the shortening be at the beginning of respiration, 
the pitch comparatively low, and vesicular quality 
be appreciable, the sign denotes emphysema. The 
diflterential points thus are, the inspiratory sound 



118 AUSCULTATION IN DISEASE. 

either unfinished or deferred, the pitch either high 
or low, and the quality either tubular or vesicular. 
Attention to these points is essential in order to 
avoid error in the interpretation of the sign. 

Prolojiged Expiration. — The length of the expira- 
tory sound in health varies in different persons. 
The sound is sometimes considerably prolonged ; it 
may be nearly as long as the sound of inspiration. 
There is no difficulty in recognizing this as a normal 
peculiarity, from the fact that the murmur has the 
pitch and quality of health. An unusual length of 
the expiratory sound, within the range of health, is 
usually observed at the summit of the chest, and 
especially on the right side. It is important to bear 
in mind that at the summit of the chest on the right 
side, and sometimes also on the left side, a prolonged 
expiratory sound, more or less raised in pitch, and 
tubular in qualit}^, may be a normal peculiarity. It 
follows that a prolonged, and even a high and tu- 
bular expiration at the summit of the chest, must 
not be reckoned as a morbid sign unless it be asso- 
ciated with other signs denoting disease. The laws 
of the disparity between the two sides of the chest 
at the summit are to be taken into account {vide p. 
87). If the expiration be longer on the left than on 
the right side, it is abnormal ; so, also, is a high- 
pitched tubular expiration heard on the left and not 
on the right side. 

The significance of an abnormally prolonged ex- 
piration depends on its pitch and quality. If it be 
high and tubular, it denotes solidification of lung. 
It is, in fact, bronchial respiration. As already 
stated, in bronchial or tubular respiration the in- 



MODIFICATIONS OF NORMAL SOUNDS. 119 

spiratory sound is sometimes wanting, and the 
presence of the sign is then to be determined by 
the characters, relating to pitch and quality, of the 
expiratory sound. The same statement holds true 
with respect to broncho-vesicular respiration when 
this approximates to the bronchial. At the summit 
of the chest, the characters of the inspiratory sound, 
and associated morbid signs, always enable the aus- 
cultator to determine whether a prolonged high and 
tubular expiration be, or be not, abnormal. A pro- 
longed expiration, which is low in pitch and blowing 
in quality, that is, with the characters of health, 
aside from length, may belong to a cavernous expi- 
ration. This is to be determined by the characters 
of the inspiration, and by other associated signs. 
Exclusive of cavernous respiration, an abnormally 
prolonged expiratory sound of low pitch and non- 
tubular, denotes vesicular emphysema. It is asso- 
ciated then with a weakened and deferred inspiratory 
sound. A prolonged expiratory sound, in cases of 
emphysema, is invariably low and non-tubular. If 
it have not these characters, it is not a sign of em- 
physema, but belongs to bronchial or broncho-vesic- 
ular respiration. Attention to these differential 
points is to be enjoined upon the student. 

A prolonged expiration at the summit of the chest 
on the right side is sometimes incorrectly considered 
to be evidence of phthisis. It is to be recollected, 
in the first place, that prolongation of this sound 
with a normal pitch and quality, is never evidence 
of solidification of lung either from phthisis or any 
other disease; and in the second place, even if the 
pitch be high, and the quality tubular, that it is not 



120 AUSCULTATION IN DISEASE. 

to be regarded as abnormal provided the inspiratory 
sound is unchanged and other signs of disease are 
not present. At times in bronchitis there is a pro- 
longed expiratory sound which may be distinguished 
as a sonorous expiration, not amounting to a rale. 
This is liable to be mistaken for broncho-vesicular 
breathing. 

The importance of observing the pitch and quality 
of a prolonged expiration was pointed out in my 
work on "Physical Exploration," in 1856. The 
difference as regards the significance of a high pitch 
with a tubular quality from a low pitch with a 
simply flowing quality, has not, as yet, received 
from medical writers the attention which it claims. 

Interrupted Respiration. — To this sign have been 
applied other names, such as jerking, wavy, cogged 
2oheel, and by French writers the names entrecoupee 
and saccadee. The modification is either of the in- 
spiration or of the expiration, or of both. The in- 
spiratory, however, much more frequently than the 
expiratory, sound is interrupted. The sound, instead 
of being continuous, is broken into one, two, or more 
parts. This is the characteristic of the sign. If at 
the same time there be alterations in pitch and 
quality, the interruption is merely incidental to 
other signs, namely, the bronchial, broncho-vesic- 
ular, or cavernous respiration. To constitute it a 
distinct sign, the interruption must be the only ap- 
preciable change. As a distinct sign it has but little 
diagnostic value. 

Interrupted respiration is sometimes found in 
healthy persons. It is confined to the summit of 
the chest, and oftener on the left than the rio'ht side. 



MODIFICATIONS OF NORMAL SOUNDS. 121 

Existing without any other signs, therefore, it is not 
evidence of disease. It is of value only in the diag- 
nosis of phthisis. Associated with other signs, when 
the latter are not marked, it is entitled to a certain 
amount of weight in the diagnosis. 

Interrupted respiratory sounds, of course, occur 
when there is interruption in the respiratory move- 
ments. This happens in cases of pleurisy, pleuro- 
dynia, or intercostal neuralgia. Owing to the pain 
caused by the movements in respiration, the patient 
may breathe, not continuously, but with a series of 
jerking movements. Sometimes interrupted breath- 
ing is observed in persons who are excited or agitated 
when auscultation is practised. In all these instances 
interruption in the respiratory sounds is found over 
the whole chest, whereas, when it is an abnormal 
sign in cases of phthisis, it is limited to the summit 
on one side of the chest, and there is no interruption 
manifested in the mode of breathing. 

Reviewing the foregoing signs, they may be dis- 
tributed into three classes, as follows : 1st. Signs, 
the distinctive characters of which relate to either 
the absence or the intensity of sound. This class 
embraces, (a) increased intensity of the vesicular 
murmur; (b) diminished intensity of the vesicular 
murmur ; and (c) suppression of respiratory sound. 
2d. Signs, the distinctive characters of which relate 
especially to pitch and quality. In this class belong, 
(a) bronchial or tubular respiration; (b) broncho- 
vesicular respiration ; (c) cavernous respiration ; (d) 
broncho-cavernous respiration ; (e) vesiculo-cavern- 
ous respiration ; and (f) amphoric respiration. 3d. 
11 



122 AUSCULTATION IN DISEASE. 

Signs, the distinctive characters of which relate 
especially to rhythm, namely, (a) shortened inspira- 
tion ; (b) prolonged expiration ; and (c) interrupted 
inspiration. 

Adventitious Respiratory Sounds, or Rales. 

Adventitious respiratory sounds, or, adopting the 
French term, rales, are distinguished from the 
morbid signs already considered, by the fact that 
they have no analogues in health ; in other words, 
they are not normal sounds abnormally modified, 
but wholly new sounds. A convenient classifica- 
tion of these signs is based on the different ana- 
tomical situations in which they are produced. 
This classification is as follows : 1st. Laryngeal and 
tracheal rales; 2d. Bronchial rales; 3d. Vesicular 
rales; 4th. Cavernous rales; 5th. Pleural rales; 
and, 6th. Indeterminate rales. Compared with 
each other, as regards their characters, they admit 
of being divided into dry and moist rales, the latter 
being evidently due to the presence of liquid. 

Laryngeal and Ti-acheal RCiles. — The rSles produced 
within the larynx and trachea may be either moist 
or dry. The moist or bubbling sounds are pro- 
duced when mucus or other liquid accumulates in 
these sections of the air-tubes. This occurs fre- 
quently in the moribund state, and the sounds are 
then known as the " death-rattles." When not in- 
cident to this state, they denote either insensibility 
to the presence of liquid, as in coma, or inability to 
effect the removal of the liquid by acts of expectora- 
tion. The sounds are heard at a distance. They 



MOIST BRONCHIAL RALES. 123 

'exemplify, on a large scale, moist or bubbling aus- 
cultatory sounds which are produced within the 
bronchial tubes. Dry sounds produced within the 
larynx or trachea are caused by spasm of the glottis, 
and by diminution of the calibre, either at or below 
the glottis, from oedema, exudation, the presence of 
a foreign body, or the pressure of a tumor. The 
dry sounds are distinguished as whistling, wheezing, 
crowing, w^hooping, etc. They are heard at a dis- 
tance, and they also exemplify auscultatory sounds 
representing analogous conditions in the bronchial 
tubes. Characteristic sounds produced at the glottis 
by spasm enter into the diagnosis of certain affections, 
namely, laryngismus stridulus, pertussis, croup, and 
aneurism involving excitation of the recurrent laryn- 
geal nerve. Other sounds are due to paralysis of 
the laryngeal muscles. Again, dry sounds produced 
by stenosis of the trachea from the pressure of an 
aneurismal or other tumor, cicatrization of ulcers, 
and morbid growths, are of diagnostic importance. 
Although audible without auscultation, these dif- 
ferent sounds, with reference to the precise situation 
at which they are produced, may sometimes be 
studied with advantage by means of the stethoscope. 
They are embraced under the name stridor. The 
respiration, voice, and cough, when accompanied by 
these sounds, are said to be stridulous. 

Moist Bronchial Rales. 

The moist bronchial ra;les are bubbling sounds 
produced in difterent branches of the bronchial tree. 
They are sounds of which the "tracheal rattles" are 



124 AUSCULTATION IN DISEASE. 

an exaggerated type. They may be imitated by 
blowing into liquids through tubes differing in size. 
They may also be produced in the lungs of the 
sheep or the calf, after removal from the body, by 
injecting into the bronchi glycerin or some other 
liquid, and imitating the respiratory acts by means 
of a pair of bellows, auscultation being practised 
with the stethoscope applied upon the surface of the 
lung, or with several thicknesses of cloth intervening. 
The bubbles seem to be large or small according to 
the size of the bronchial tubes in which they are 
produced. Apparent differences in the size of the 
bubbles are distinguished by the names coarse and 
fine. In the primary and secondary bronchial 
branches the moist sounds are relatively quite 
coarse; they are less so in tubes of the third or 
fourth dimensions; in smaller tubes they become 
fine, and in those of minute size they become ex- 
tremely fine. Extremely tine bubbling sounds con- 
stitute what has been known as the subcrepitant 
rale, so called because it approaches in character to 
the crepitant rSle produced within the air-vesicles 
and bronchioles. We may thus judge of the size of 
the bronchial tubes in which the rales are produced 
by their comparative coarseness or fineness. Fre- 
(juently, however, coarse and fine rales are inter- 
mingled, and generally those which are either coarse 
or fine are not uniform, but appear to be of unequal 
size. In all the varieties of the moist bronchial r^les, 
the bubbling character of the sounds is sufficiently 
distinctive for their recognition. The ditterentiation 
of the so-called subcrepitant from the crepitant rale 
alone involves some nice points of distinction. 



MOIST BRONCHIAL RALES. 125 

Coarse bubbling rales sometimes occur in acute 
bronchitis affecting the larger bronchial tubes. 
Their occurrence is exceptional, because, in gen- 
eral, the mucus within the tubes does not ac- 
cumulate sufficiently and is too consistent for the 
production of bubbling sounds. These rales occur 
in cases in which the mucus is unusually thin and 
either more abundant than usual or an accumulation 
takes place in consequence of inability to expec- 
torate freely. These conditions are wanting in the 
majority of the cases of ordinary acute bronchitis. 
A muco-purulent liquid in cases of chronic bron- 
chitis is better suited for the production of bubbling 
sounds than simple mucus. Moreover, coarse r^les 
are heard oftener in children than in adults, because 
the former do not voluntarily expectorate as freely 
as the latter. Serous transudation (bronchorrhcea) 
into tubes of large size may give rise to coarse bub- 
bling rales, and also the presence of blood in some 
cases of profuse hemorrhage. In bronchitis and 
bronchorrhcea the rales are heard on both sides of 
the chest. The bubbling rMes, whether coarse or 
fine, are heard either with the act of inspiration or 
of expiration, or with both acts. 

Fine bubbling sounds and the so-called subcrepi- 
tant rale occur in various pathological connections. 
The characters of the latter are to be borne in mind 
with reference to the discrimination from the crepi- 
tant rale. The most distinctive character is the 
moist sound or bubbling; this is sufficiently appre- 
ciable. Other characters are, their occurrence fre- 
quently, but not constantly, in expiration as well as 
11* 



126 AUSCULTATION IN DISEASE. 

in inspiration, and the inequality of the fine bubbling 
sounds. 

The so-called subcrepitant rale, existing over the 
chest on both sides, is diagnostic of bronchitis affect- 
ing the smaller bronchial tubes (capillary bronchitis), 
when taken in connection with other signs and the 
symptoms. The rSle exists on both sides, because 
this, as well as bronchitis affecting the larger tubes, 
is a bilateral affection. The sign is of great prac- 
tical value in the diagnosis of that variety of bron- 
chitis. The rale also occurs on both sides, and is 
more or less diffused in pulmonary cedema. The 
connection with the latter affection is shown by the 
associated physical signs, together with the symp- 
toms. In so-called capillary bronchitis, the bubbling 
is due to the presence of thin mucus, and in pulmo- 
nary^ oedema to serous transudation within the small 
bronchial ramifications. 

Fine bubbling or the so-called subcrepitant rale 
has other pathological connections, as follows : 

1. It occurs in lobar pneumonia during the stage 
of resolution. Here it is due to the presence of 
mucus from a bronchitis limited to the affected lobe 
or lobes, and, in a measure, to liquefied pneumonic 
exudation. It is considered as denoting commenc- 
ing and progressing resolution in pneumonia. Some- 
times it is intermingled with rales which are more or 
less coarse. 

2. In circumscribed pneumonia, hemorrhagic in- 
farctus, and pulmonary apoplexy, the fine or sub- 
crepitant rale, often associated with those which are 
more or less coarse, denotes the presence of mucus 
or of blood within the bronchial tubes. The rSles 



MOIST BRONCHIAL RALES. 127 

are localized in space, or in spaces, corresponding to 
the situation and extent of the affection. 

3. During and shortly after a haemoptysis, fine 
r^les limited to a particular situation are sometimes 
heard, proceeding from blood in the small bronchial 
tubes, and indicating the situation of the hemorrhage, 

4. A purulent liquid admits of bubbling much 
more readily than mucus ; hence, in cases of chronic 
bronchitis with an expectoration of pus, fine and 
coarse bronchial rales are more frequent than in 
acute bronchitis. Pus, also, may be present within 
bronchial tubes of small size, not as a product of 
bronchitis, but from the evacuation of an abscess of 
either the pulmonary parenchyma, of the liver or 
some other adjacent part, and from perforation of 
lung in some cases of empyema. 

5. In the different stages of phthisis, moist bron- 
chial rales are usually present. The liquid in the 
tubes, if the disease be advanced, is derived, in part, 
from associated bronchitis, and, in part, from lique- 
fied tuberculous exudation. The bubbling sounds 
may be more or less coarse or fine, and both are 
often intermingled. Early in the disease, before 
softening of the exudation has taken place, fine 
bubbling, or the subcrepitant rale, limited to the 
summit of the chest, is an important diagnostic 
sign. It belongs among the accessory physical 
signs on which the diagnosis may depend. Here 
the liquid is derived from a coexisting circum- 
scribed bronchitis. 

In cases of fibroid phthisis, or cirrhosis of lung, 
moist r^les, coarse and fine, are generally more or 



128 AUSCULTATION IN DISEASE, 

less abundant and diftused over the whole, or the 
greater part, of the chest on the affected side. 

In the foregoing account of the moist bronchial 
rales, the subcrepitant rale is not reckoned as a sign 
distinct from fine bubbling sounds. Inasmuch as 
the mechanism and the significance are the same, 
and it is not easy to draw a line of demarcation 
between the two, the distinction is unimportant. It 
is sufficient to bear in mind that very fine bubbling 
sounds are called subcrepitant, because they are 
somewhat analogous to the crepitant rUle. The 
points which distinguish the latter are, however, 
well marked, as will appear when the characters of 
that sign are considered. The term subcrepitant 
gives rise to confusion, and there is no advantage in 
retaining it as the name of a distinct sign. Yery 
fine bubbling expresses more correctly the characters 
of the sign. The moist rales are often called mucous 
rales. This name is obviously inappropriate, since, 
not only are the sounds produced by other liquids 
than mucus, but other liquids are best suited for 
their production, especially in the large and medium- 
sized tubes. 

The several varieties of the moist bronchial rales 
may be produced by the injection of a liquid in 
varying quantity into the bronchi of the lungs re- 
moved from the body of an animal of sufficient size, 
e. g.^ of the sheep or calf, and imitating respiration 
by means of bellows. 

The moist bronchial rales, whether coarse or fine, 
vary in pitch accordingly as the lung surrounding 
the tubes in which they are produced is, or is not, 
solidified. If the lung be solidified, the pitch is 



DRY BRONCHIAL RALES. 129 

high; if there be no solidification, the pitch is com- 
paratively low. Thus, the pitch of the rales is high 
in the second stage of pneumonia and in phthisis 
with considerable solidification, whereas the pitch 
is low in bronchitis and pulmonary cedema. If, 
therefore, the respiratory sound be suppressed, it is 
easy to determine by the pitch of these rales whether 
the lung be solidified or not, and to judge measur- 
ably of the degree of solidification. Attention to 
the pitch in connection with these rales is sometimes 
of value in diagnosis. 

Dry Bronchial Rales. 

All adventitious sounds which are not moist, pro- 
duced within the air-tubes below the trachea, are 
embraced under the name dry bronchial rales. The 
sounds are many and varied in character. They are 
often musical notes. Frequentlj^ they are sugges- 
tive of certain familiar sounds, such as the chirping 
of birds, the cry of a young animal, snoring in sleep, 
cooing of pigeons, humming of the mosquito, the 
note of the violoncello, etc., etc. They are often 
heard at a distance, and characterized as wheezing 
sounds. An interrupted or clicking sound is not 
uncommon. All these varieties are practically un- 
important, and it would be a needless refinement to 
consider particular varieties as distinct signs. The 
only distinction which it is desirable to make is into 
the sibilant and sonorous rales. This distinction is 
based on difference in pitch; sibilant rales are high, 
and sonorous rales are low in pitch. As a rule, the 
sibilant rales are produced in the small and the 



130 AUSCULTATION IN DISEASE. 

sonorous rales in the larger sized bronchial tubes. 
The sounds may accompany either inspiration or ex- 
piration, or both. The sibilant and sonorous rales 
are often intermingled. There may be sibilant rales 
with inspiration, and sonorous rales with expiration, 
within the same situation. Moreover, these rales 
are found often to vary from minute to minute, 
being at one instant sibilant and at another sonor- 
ous. Students are liable to confound sonorous rales 
with bronchial breathing and sometimes friction- 
sounds. 

The physical condition represented by the dry 
rales is diminished calibre of the air-tubes at certain 
points, and especially in consequence of spasm of 
the bronchial muscular libres. The latter consti- 
tutes the essential pathological condition in a par- 
oxysm of asthma; and in this aiiection the dry rales 
are always marked. Their diagnostic importance 
relates chiefly to asthma. Both sibilant and sonor- 
ous rfdes are present and diffused over the entire 
chest. Wheezing sounds with expiration are heard 
by the patient, and by others at a distance. A 
single paroxysm of asthma aifords an opportunity 
for the student to obseive all the varieties and 
fluctuations of these rfdes. Taken in connection 
with other signs and the symptoms, the rales are 
pathognomonic of asthma. 

More or less spasm of the bronchial muscular 
flbres occurs in certain cases of bronchitis, without 
being sufficiently great and extensiv^e to give rise to 
a paroxysm of asthma, or even any embarrassment 
of respiration. Under these circumstances the rales 
are less marked and diffused. An asthmatic element 



VESICULAR OR CREPITANT RALE. 131 

may be said to enter, more or less, into these cases. 
Narrowing of bronchial tubes by tenacious mucus 
which gives rise to no bubbling sounds, and, per- 
haps, unequal swelling of the mucous membrane, 
may also occasion sibilant and sonorous rales. 

Dry rales at the summit of the chest are not 
infrequent in cases of phthisis due to spasm, the 
presence of mucus, or to swelling of the mucous 
membrane. They are sometimes quite annoying to 
phthisical patients. 

Clicking sounds are suggestive of the sudden 
separation of tenacious mucus from the walls of the 
bronchial tubes. These are sufficiently common in 
bronchitis and in phthisis. 

Vesicular or Crepitant Rale. 

This is the only vesicular rale. It is usually con- 
sidered to be produced within the air-vesicles, but 
probably, the terminal bronchial tubes or bronchioles 
participate in its production. 

It is to be distinguished from very fine bubbling 
sounds, or the so-called subcrepitant rk\e. The 
points of distinction are as follows : The sounds are 
not moist but dry ; they are crackling, not bubbling 
in character. They may be defined to be very fine, 
dry, crackling sounds. This point of difiierence is 
very distinctive. There are, however, other differ- 
ential points. The crackling sounds are equal, 
whereas, fine bubbling sounds are unequal, that is, 
they give the impression of bubbles of unequal size. 
The crepitating sounds are heard at the end of the 
inspiratory act, and especially at the end of a forced 



132 AUSCULTATION IN DISEASE. 

inspiration, the subcrepitaut rale, on the other hand, 
being heard often witli or near the beginning of in- 
spiration, and, perhaps, ceasing before the end of 
the inspiratory act. Another distinctive feature is 
the abrupt development of the crepitant rale ; there 
is a shower of crackles, as it were, at the end of a 
forced inspiration. Finally, the nlle is never heard 
in expiration. The apparent exceptions to this 
statement are instances in which the crepitant and 
the subcrepitaut rale are associated. This is not 
very infrequent, and, with a practical knowledge of 
the characters of each, it is by no means difficult to 
appreciate the combination of the two signs. In 
fact, the combination affords an excellent opportunity 
to illustrate the distinctive characters of each ; the 
tine bubbling at or near the beginning of inspiration, 
followed b}^ the tine crackling at the end of this act, 
and the former perhaps reproduced in the act of 
expiration. 

There are various modes in which the crepitant 
rale may be imitated ; for example, rubbing together 
a lock of hair near the ear, throwing tine salt upon 
live coals or into a heated vessel, igniting a train of 
gunpowder, and alternately pressing and separating 
the thumb and finger moistened with a solution of 
gum arable and held near the ear. A perfect repre- 
sentation is afforded by squeezing a piece of an 
artificial preparation known as the India-rubber 
sponge, and observing the sound produced by the 
separation of the walls of the interstices when the 
piece expands from its elasticity. This preparation 
exemplifies the true mechanism of the sign as de- 
scribed, first, by the late Dr. Carr, of Canandaigua, 



VESICULAR OR CREPITANT RALE. 133 

Is. Y., in an article published in the American Journal 
of Medical Sciences, in October, 1842.^ Expansion of 
the lungs of the sheep or calf, after removal from 
the body, the stethoscope being applied to the lung- 
surface, gives, in certain situations, a w^ell-marked 
crepitant rale. 

The crepitant rale is the diagnostic sign of pneu- 
monia. It very rarely occurs in any other patho- 
logical connection. Of all respiratory signs, this is 
most entitled to be called pathognomonic. It be- 
longs especially to the first stage of acute pneumonia. 
It is not invariably present, but it occurs in the 
majority of cases of acute pneumonia. In the second 
stage, or the stage of solidification, the rale generally 
disappears. It not infrequently is reproduced in the 
stage of resolution, and it is then called the return- 
ing crepitant rale. In the latter stage it is often 
found in combination with the subcrepitant rsile. 
The practical value of this sign relates chiefly to the 
diagnosis of pneumonia. 

It is stated that the crepitant rale is sometimes 
found in cases of pulmonary oedema, and during or 
directly after an attack of haemoptysis. If it ever 
occur in these cases, the instances must be extremely 
rare. The statement is perhaps based on the occur- 
rence of the subcrepitant, this being confounded 
with the crepitant rale. It occurs transiently under 
the following circumstances : A patient who has 
been confined for some time in bed, lying on the 
back, and much enfeebled with any disease, if sud- 
denly raised to a sitting posture and auscultated, a 

^ Vide article by the author in the New York Monthly Med. 
Journ. for Feb. 1869. 

12 



134 AUSCULTATION IN DISEASE. 

crepitant rale is often found on the posterior aspect 
of the chest at the end of a forced inspiration. The 
rale disappears after a few forced inspirations. It is 
heard, not on one side only, but on both sides. The 
explanation is, that during the recumbent posture 
continued for some time, and the patient breathing 
feebly, enough of the air-vesicles and bronchioles 
become agglutinated by means of a little sticky 
transudation to give rise to crackling sounds in a 
few forced inspirations. It may be of use to men- 
tion that if the stethoscope be applied to the anterior 
surface of a chest much covered with hair, the move- 
ments of the pectoral extremity of the instrument in 
the act of inspiration may produce a sound identical 
with the crepitant rale. 

A crepitant rale at the summit of the chest, within 
a circumscribed space, is one of the accessory signs 
of phthisis. It denotes a circumscribed pneumonia 
which clinical experience shows to be generally 
secondary to phthisis ; hence the diagnostic signifi- 
cance of the sign. 

Cavernous or Gurgling Rale. 

A pulmonary cavity of considerable size, contain- 
ing a certain quantity of liquid, and communicating 
freely with bronchial tubes, furnishes a rfde which 
is characteristic. The character of the sound is ex- 
pressed as fully as possible by the term gurgling. 
The sound is produced by large bubbling and the 
agitation of the liquid within the cavity. It may be 
compared to the sound produced by the boiling of a 
liquid in a flask or large test-tube. The sound is 



FRICTION-SOUNDS. 135 

sometimes high pitched and amphoric, but generally 
it is low in pitch. It is heard with more or less 
intensity within a circumscribed space almost in- 
variably at or near the summit of the chest ; but, if 
intense, the sound is diffused, and it may be some- 
times heard at a distance. Its diagnostic importance 
relates to the advanced stage of phthisis. The rale 
is heard chiefly or exclusively in the act of inspira- 
tion. It may be produced by the act of coughing 
sometimes with greater intensity than by respiration. 

Pleural Rales— Friction-Sounds — Metallic Tinkling — 
Splashing. 

The signs embraced under the name pleural rSles 
are, 1st. Sounds produced by the rubbing together 
of the pleural surfaces, and hence called friction- 
sounds; 2d. Metallic tinkling; and 3d. Splashing 
or succussion sounds. 

Friction- Sounds. — Movements of the pleural sur- 
faces upon each other take place in inspiration and 
expiration ; but in health these movements occasion 
no sound. Sounds are produced when the surfaces 
are covered with a recent fibrinous exudation which 
prevents the normal continuous, unobstructed move- 
ments, and when the surfaces are roughened with 
dense lymph or other morbid products. The sounds 
are generally interrupted, that is, two, three, or 
more sounds occur during the act of inspiration or 
expiration, or during both acts. The intensity of 
the sounds varies much in different cases. A slight 
grazing sound only may be heard, or, on the other 
hand, the sounds may be so loud as to be heard by 



136 AUSCULTATION IN DISEASE. 

the patient and by others at a distance. The char- 
acter of the sounds is variable. The slight rubbing 
or grazing character may be imitated by placing 
over the ear the palmar surface of one hand, and 
moving over its dorsal surface slowly the pulpy por- 
tion of a finger of the other hand. In some instances, 
however, the rough character of the sounds is ex- 
pressed by such terms as rasping, grating, and creak- 
ing. In these instances the sounds denote density 
of the morbid product which roughens the pleural 
surfaces. In connection with very rough sounds, 
vibration of the walls of the chest, or fremitus, is 
sometimes perceived by palpation. 

Aside from the character of the sounds as just 
stated, they are distinguished by their apparent 
nearness to the ear; they seem sometimes to be pro- 
duced upon the surface of the chest. They are 
sometimes intensified by firm pressure of the stetho- 
scope upon the chest. After a little practical knowl- 
edge of these sounds they can hardly be confounded 
with any other rales. 

Pleuritic friction-sounds generally denote pleurisy. 
In cases of pleurisy with eflEusion, slight rubbing or 
grazing is sometimes heard before much liquid ac- 
cumulates within the pleuritic cavity. The physical 
conditions, however, after the efiPusion has been re- 
moved, are much more favorable for the production 
or friction-sounds, and they are often now rough in 
character. They may be transient, or they may 
continue for a considerable period, their duration 
depending on the arrest of the movements of the 
pleural surfaces by means of either agglutination 



METALLIC TINKLING. 137 

with lymph, or adhesion from the growth of areolar 
tissue. 

Pleuritic friction-sounds occur not infrequently in 
cases of pneumonia, denoting, in this connection, 
coexisting pleurisy. 

Slight rubbing or grazing at the summit of the 
chest is one of the accessory signs of phthisis. It 
denotes a circumscribed, dry pleurisy, which, as 
clinical experience shows, is generally secondary to 
phthisis, and hence the diagnostic significance of 
the sign. 

In the foregoing instances in which friction-sounds 
are stated to occur, their significance relates to 
pleurisy. In some rare instances the sounds are 
produced by miliary tubercles or carcinomatous 
nodules projecting beyond the plane of the visceral 
pleural surface, without pleuritic inflammation. 

Metallic TiiMijig. — This is a vocal as well as a re- 
spiratory sign. It is also produced by acts of cough- 
ing, and sometimes by the act of deglutition. The 
name expresses the distinctive character of the sign. 
It consists in a series of tinkling sounds of a high- 
pitched, silvery, or metallic tone. The number of 
sounds varies from a single sound, to two, three, or 
more sounds, during an act of either inspiration or 
expiration. This sign may be imitated in various 
ways, by means of an India-rubber bag of consider- 
able size. Forcing a liquid into the bag with 
Davidson's syringe, tapping the bag with the finger, 
or shaking it, will produce tinkling sounds. The 
best mode of artificial representation of the sign is 
to connect the bag with a flexible tube, the latter 
containing a few drops of liquid, and blowing into 
12* 



138 AUSCULTATION IN DISEASE. 

the tube so as to produce bubbles at the communi- 
cation of the tube with the bag. In this latter ex- 
periment it is not necessary that the bag contain any 
liquid. It occurs irregularly, that is, it is not present 
in every act of breathing, but is heard at variable 
intervals. It may sometimes be produced by forced, 
when it is not heard in tranquil, breathing. It can 
only be confounded with tinkling sounds sometimes 
produced within the stomach. The latter, however, 
are easily discriminated by their situation, and the 
absence of associated signs denoting the affections of 
the chest in which the sign occurs. 

Metallic tinkling is the sign of pneumothorax with 
perforation of lung. In the great majority of the 
cases in which it is found, it is diagnostic of this 
aftection. It is, however, always associated with 
other physical signs corroborative of the diagnosis. 

It is a rare sign, in cases of phthisis, of a large 
pulmonary cavity, the conditions for its production 
being analogous to those in pneumo-hydrothorax, 
namely, a space of considerable size containing air, 
the space communicating with bronchial tubes. 

Splashing, or Succussion Sounds. — This sign is pro- 
duced by succussion, which is reckoned as one of 
the difierent modes of physical exploration. Sounds 
thus produced are not infrequently heard at some 
distance ; generally, however, succussion is practised 
while the ear is applied to the chest, so that properly 
enough the sign may be embraced among the aus- 
cultatory signs, although not produced by respiration. 

Splashing is pathognomonic of either pneumo- 
hydrothorax or pneumo-pyothorax. It is especially 
valuable as a sign of these afiections because it is 



INDETERMINATE RALES. 139 

almost invariably available. The instances are ex- 
tremely few in which the sign is wanting when air 
and liquid are contained in the pleural cavity. It 
is obtained by jerking the body of the patient with 
a quick, somewhat forcible movement, the ear being 
very near to, or in contact with, the chest. 

The sound is like that produced when a bottle 
partially filled with liquid is shaken. The sound is 
often high-pitched and amphoric in quality. The 
only liability to error is in confounding with this 
sign, splashing produced within the stomach. At- 
tention to other signs will always protect against 
this error. 

Indeterminate Redes. — Under this head may be em- 
braced some sounds sufficiently recognizable, but 
indeterminate as regards the rationale of their pro- 
duction and the physical conditions which they rep- 
resent. They may be designated crumpling and 
crackling sounds. The former are probably due to 
pleuritic rubbing, and the latter to the separation of 
some slightly adherent air-vesicles or bronchioles. 
Their diagnostic value relates only to the early stage 
of phthisis. In conjunction with other signs, any 
indeterminate rale, if limited to the summit of the 
chest, and especially to one side, has some weight in 
the diagnosis. Crumpling and crackling sounds, 
however, are not uncommon in healthy persons at 
the end of forced inspiration. The fact of their 
presence at both summits, and the absence of other 
morbid signs, are the grounds for not considering 
them as evidence of disease. They are found in 
health especially if the binaural stethoscope be em- 
ployed. Their diagnostic significance, thus, depends 



140 AUSCULTATION IN DISEASE 

on limitation to the summit of the chest on one side, 
and association with other signs pointing to incipient 
phthisis. 

The Vocal Signs of Disease. 

The vocal signs of disease, with the exception of 
metallic tinkling, which is a vocal as well as respira- 
tory sign, may all be considered as abnormal modi- 
fications of the normal vocal resonance and of the 
normal bronchial whisper. The student must, there- 
fore, be familiar with the distinctive characters of 
these two normal signs before he is prepared to enter 
upon the study of the abnormal modifications {vide 
pages 90 and 95). He must bear in mind the facts 
which have been presented in relation to the normal 
vocal fremitus {vide page 90). The rules given for 
auscultation of the voice are also to be observed (vide 
page 91). Embracing the abnormal modifications 
of the loud voice, the whisper and fremitus, the fol- 
lowing are the signs to be considered : Broncho- 
phony; Whispering Bronchophony; ^Egophony; 
Increased Vocal Resonance; Increased Bronchial 
Whisper; Cavernous Whisper ; Pectoriloquy; Am- 
phoric Voice or Echo ; Diminished and Suppressed 
Vocal Resonance ; Diminished and Suppressed Vocal 
Fremitus, and Metallic Tinkling. 

Bronchophony. 

Bronchophony has the same import as bronchial 
or tubular respiration. Like the latter sign, it rep- 
resents complete or considerable solidification of 
lung. Generally the two signs are associated, but 
either may be present without the other. 



BRONCHOPHONY. 141 

The characters which are distinctive of broncho- 
phony, as compared with the normal vocal resonance, 
are these : The vocal sound seems concentrated, in 
most cases near the ear, and the pitch is more or less 
raised. These characters are in contrast with the 
diffusion, distance, and lowness of pitch of the nor- 
mal vocal resonance. The intensity of the sound is 
variable ; it may be greater or less than the intensity 
of the normal resonance. A concentrated, high- 
pitched sound, however feeble, is not less a sign of 
complete or considerable solidification of lung, that 
is, it is not less bronchophony, than when the sound 
is intense. 

Yocal fremitus is always to be discriminated from 
vocal resonance. The fremitus associated with 
bronchophony may, or may not, be greater than the 
fremitus of health. ISTot infrequently the fremitus 
is less than in health. 

It is to be borne in mind that in some healthy 
persons bronchophony exists at the summit of the 
chest, especially on the right side, over the primary 
bronchus. Existing in this situation, it may not be 
abnormal. 

Kepresenting complete or considerable solidifica- 
tion of lung, this sign occurs in the different affec- 
tions in which bronchial or tubular respiration has 
been seen to occur {vide page 107), namely, lobar 
pneumonia, phthisis, chronic or fibroid pneumonia, 
condensation of lung from either pleuritic effusion, 
the accumulation of air in the pleural cavity or the 
pressure of a tumor, collapse of pulmonary lobules, 
coagulation of blood within the air-vesicles, and car- 
cinoma of lung. 



142 AUSCULTATION IN DISEASE. 

For the production of bronchophony, a less degree 
of solidilication is requisite than for the production 
of bronchial or tubular respiration. Hence, bron- 
chophony may be associated with abroncho-vesicular, 
as well as with a purely bronchial, respiration. This 
is illustrated in the resolving stage of pneumonia. 
When resolution has progressed sufficiently for the 
bronchial to give place to the broncho-vesicular res- 
piration, well-marked bronchophony is often found 
to continue, ceasing at a later period in the resolving 
stage. 

The apparent nearness to the ear of the vocal 
sound in bronchophony is wanting if a certain quan- 
tity of liquid intervene between the solidified lung 
and the walls of the chest at the situation auscultated. 
The voice under these conditions seems to be more 
or less distant. This difference is readily appre- 
ciated. With this apparent distance of the broncho- 
phonic voice, in some instances is associated the 
modification which is characteristic of another sign, 
namely, tegophony. 

Whispering Bronchophony. 

The characters of this sign correspond to those of 
the expiratory sound in the bronchial or tubular 
respiration {vide page 107). The sound is more or 
less intensified, high in pitch, and tubular in quality. 
If tlie patient pronounce numerals in a forced whis- 
per, the characters are generally more marked than 
in the expiratory sound in forced breathing. The 
significance of this sign is the same as that of the 
bronchial or tubular respiration, and of broncho- 
phony with the loud voice. 



VOCAL RESONANCE AND FREMITUS. 143 

.ffigophony. 

This sign is a modification of bronchophony. As 
regards concentration and pitch, it has the characters 
of bronchophony, the distinctive features being ap- 
parent distance from the ear, and trenmlousness or 
a bleating tone. From the latter the name is de- 
rived, the term signifying the cry of the goat. The 
characters which distinguish the sign from broncho- 
phony are readily enough appreciated, and it repre- 
sents a physical condition added to solidification of 
lung. This physical condition is the presence of 
liquid efiusion. The sign is rarely present in cases 
of large efiusion. It occurs usually when the chest 
is about half filled with liquid, and the lung at the 
level of the liquid is sufliciently condensed to give 
rise to bronchophony. This condition, under these 
circumstances, involves agglutination of lung above 
the portion condensed by pressure. The sign also 
sometimes occurs in cases of pleuro-pneumonia, the 
solidification in these cases being due to pneumonic 
exudation. As a sign of liquid efiusion it possesses 
diagnostic value, although, owing to the fact that 
the existence of effusion is easily determined by 
other signs, it may be said to be superfiuous. When 
the person examined speaks with the teeth approxi- 
mated, bronchophony has somewhat of the character 
of segophony. 

Increased Vocal Resonance and Fremitus. 

The distinctive character of this sign is an increase 
of the intensity of the resonance without notable 
change in other respects. The resonance may be 



144 AUSCULTATION IN DISEASE. 

more or less intensified, but it is distant, diifased, 
and comparatively low in pitch ; in other words, the 
characters distinctive of bronchophony are wanting. 
The differential points between bronchophony and 
increased resonance should be clearly apprehended, 
bearing in mind that the intensity of the sound in 
bronchophony may, or may not, be greater than the 
normal resonance. 

Increased vocal resonance occurs when the lung 
is solidified, the solidification not sufficient in degree 
to produce bronchophony. Lung slightly or mod- 
erately solidified gives rise to an increase of the 
intensity of the resonance of the voice; if the solidi- 
fication become considerable or complete, broncho- 
phony takes the place of the simple increase of 
intensity. Thus, at an early period in pneumonia, 
increased vocal resonance precedes bronchophony ; 
and in the stage of resolution the reverse of this 
takes place, namely, increased vocal resonance fol- 
lows bronchophony, the latter ceasing when resolu- 
tion has progressed to a certain extent. 

Contrary to what would perhaps be anticipated in 
the instances just cited, the intensity of the sound 
when bronchophony is present may be not only not 
increased, but diminished below that of health ; that 
is, in the first stage of pneumonia the increased in- 
tensity may cease when bronchophony occurs, and 
return when bronchophony disappears. 

Increase of the vocal resonance occurs in connec- 
tion with pulmonary cavities. Over a cavity of con- 
siderable size situated near the superficies of the lung, 
the vocal resonance is sometimes extremely intense 
without any bronchophonic characters. The latter, 



VOCAL RESONANCE AND FREMITUS. 145 

if present, denote considerable solidification either 
around the cavity, or between it and the walls of the 
chest. From the presence or the absence of bron- 
chophonic characters with greatly increased intensity 
of resonance, the auscultator can judge whether the 
cavity be, or be not, in proximity to considerable 
solidification of lung. 

Irrespective of the cavernous stage of phthisis, the 
sign is of diagnostic importance in the different 
aflt'ections v^hich involve moderate or slight solidifi- 
cation of lung, namely, pneumonia early in the dis- 
ease and in the stage of resolution, phthisis, over the 
compressed lung in pleurisy with moderate effusion, 
collapse of pulmonary lobules, hemorrhagic infarctus. 
and carcinoma of lung. Into the diagnosis of all 
these affections, both bronchophony and increased 
vocal resonance enter ; the former when solidifica- 
tion is considerable or complete, and the latter when 
it is slight or moderate. Increased vocal resonance 
is especially valuable in the diagnosis of early or 
incipient phthisis. An abnormal resonance, how^- 
ever slight, at the summit of the chest on one side, 
is an important sign in that affection. In determin- 
ing an abnormal resonance on the right side, either 
at the summit or elsewhere, allowance must always 
be made for the normally greater resonance on this 
side. 

Increased vocal resonance has the same import as 
broncho-vesicular respiration. These two signs, 
however, are not always in the same proportion ; 
that is, the characters of the latter may be marked 
out of proportion to the amount of the increase of 
the vocal resonance, and vice versa. 

13 



146 AUSCULTATION IN DISEASE. 

Increased vocal fremitus generally accompanies 
increased vocal resonance, and it denotes solidiiica- 
tion of lung. Fremitus, however, and resonance are 
not always in equal proportion, that is, either may 
be increased more than the other. An increased 
fremitus is sometimes of value in the diagnosis of 
phthisis. The greater fremitus on the right side of 
the chest is always to be borne in mind, and due 
allowance is to be made for this disparity in deter- 
mining that the fremitus is increased. 

Increased BroncMal Whisper, 

The significance of this sign is the same as that of 
increased vocal resonance and the broncho-vesicular 
respiration ; it represents the same physical condition 
as the two latter signs, namely, solidification of lung, 
greater or less, but below the degree requisite to give 
rise to bronchophony and bronchial respiration. Its 
diagnostic application is, therefore, involved in the 
same pulmonary affections. 

The characters of the sign are those wdiich belong 
to the expiratory sound in the broncho-vesicular 
respiration. They consist, therefore, of increase of 
intensity, a quality more or less tubular, and the 
pitch raised, these modifications of the normal ex- 
piratory sound varying in degree between the 
slightest appreciable morbid change and a close ap- 
proximation to the bronchophonic whisper. The 
modifications in degree correspond to the degree of 
solidification. To appreciate the characters of this 
sign, it must be studied in comparison with those of 
the normal bronchial whisper in difterent portions 



INCREASED BRONCHIAL WHISPER. 147 

of the chest. The most important of the diagnostic 
applications of the sign is in cases of phthisis in its 
early stage. In this application, the points of nor- 
mal disparity between the two sides of the chest at 
the summit are to be borne in mind, and due allow- 
ance made for them {vide page 96.) 

A greater intensity of the bronchial whisper at the 
right than at the left summit is not evidence of dis- 
ease ; but greater intensity at the left summit is 
always abnormal. As a rule, the pitch of the nor- 
mal bronchial whisper at the left, is higher than that 
at the right, summit ; if, therefore, with a greater 
intensity of the whisper at the right summit, it be a 
matter of doubt whether it denote disease or not, 
when the pitch is higher at this summit it is to be 
considered as morbid. 

Cavernous Whisper. — The characters distinctive of 
the cavernous whisper are those of the expiratory 
sound in the cavernous respiration, namely, lowness 
of pitch, and the quality blowing, that is, non-tubular. 
The intensity of the sound is variable. It is limited 
to a circumscribed space corresponding to the situa- 
tion and size of the cavity. IN'ot infrequently the 
characters of the sign are brought into contrast with 
those of whispering bronchophony, or increased 
bronchial whisper, these latter signs existing in close 
proximity, and representing solidification of lung in 
the immediate neighborhood of the cavity. The 
diagnostic application of this sign is chiefly to ad- 
vanced phthisis. 

Pectoriloquy. — In pectoriloquy, not merely the 
voice, but the speech, is transmitted through the 
chest; the auscultator recognizes words uttered by 



148 AUSCULTATION IN DISEASE. 

the patient. The student, however, must not expect 
to be able to carry on a conversation with the patient 
by means of the stethoscope. Often single words 
only can be recognized. To make sure that these 
are transmitted through the chest, care must be 
taken to exclude their direct transmission from the 
patient's mouth, and the auscultator should not 
know beforehand the words which are to be spoken. 
If these rules be not observed, the auscultator may 
err in supposing that the words are transmitted 
through the chest. When auscultation is practised 
with one ear, the other should be closed. 

The speech with either the loud or the whispered 
voice may be transmitted, the latter, distinguished 
as whispering pectoriloquy, being much more fre- 
quent than the former; moreover, in determining 
whispering pectoriloquy, there is less liability to 
error in mistaking the perception of words coming 
directly from the mouth for the transmission through 
the chest. In the production of this sign, much de- 
pends on the distinctness with which words are 
articulated by the patient. ITormal pectoriloquy at 
the anterior superior portion of the chest is some- 
times observed. 

Pectoriloquy belongs among the cavernous signs; 
but it is by no means exclusively the sign of a cavity; 
the speech may also be transmitted by solidified lung. 
It is easy to determine in any case whether the sign 
denotes a cavity or solidified lung. If, with trans- 
mitted speech, the voice have the characters of 
bronchophony, the sign represents solidification of 
lung; if, on the other hand, the characters of bron- 
chophony be wanting, the sign represents a cavity. 



INCREASED BRONCHIAL WHISPER. 149 

These statements apply equally to the loud and to 
the whispered voice. Of course, associated signs 
will be likely to show whether a cavity exists or 
not. It is to be added that a cavity and solidification 
of lung existing together, may conjointly be con- 
cerned in the production of the sign. 

Amphoric Voice or Echo. — This sign is identical in 
character with amphoric respiration, with which it 
is usually associated {vide page 115). The amphoric 
intonation may accompany the loud voice and the 
whisper; generally, it is more appreciable or marked 
with the latter. Its significance is the same as that 
of amphoric respiration. As a rule, it represents 
the conditions in pneumothorax, namely, a large 
space filled with air and perforation of lung. In this 
affection it is associated with other signs which sufiice 
for a prompt and positive diagnosis. It is not inva- 
riably found in pneumothorax, and it may be present 
in a case at one time and wanting at another time, 
its production being dependent on the perforation 
being above the level of liquid, if the latter exist, 
and on the bronchial tubes leading to the perfora- 
tion being unobstructed. When not associated with 
other signs which are diagnostic of pneumothorax, 
it denotes a phthisical cavity of considerable size. 
It is not infrequently a sign of a phthisical cavity 
with rigid walls and communicating freely with 
bronchial tubes. It has this significance whenever 
pneumothorax can be excluded ; and the associated 
signs in the latter aftection are such that its exclu- 
sion is always practicable. 

The amphoric sound sometimes is observed to 
13* 



150 AUSCULTATION IN DISEASE. 

follow tlie oral voice; hence, the name amphoric 
echo. 

Diminished and Suppressed Vocal Resonance. — 
Diminution and suppression of the normal vocal 
resonance occur especially when the pleural cavity 
contains either liquid or air. "Whenever the lungs 
are not in contact with the walls of the chest, the 
vocal resonance, as a rule, is either notably lessened 
or wanting. The sign is, therefore, of value in 
diagnosis in cases of pleurisy with effusion, em- 
pyema, hydrothorax, and pneumothorax. When 
the pleural cavity is partially filled with liquid, there- 
is diminution or suppression of the resonance from 
the level of the liquid downward; and generally, 
just above the level of the liquid, the resonance is 
increased, owing to condensation of the lung. The 
sign is well illustrated by the contrast in such cases 
above and below the level of the liquid. As a rule, 
the changes of the level of the liquid with changes 
in position of the body, may be as well demonstrated 
by means of vocal resonance as by percussion. Ex- 
ceptionally, however, this rule is not available. 

The practical importance of diminished and sup- 
pressed vocal resonance relates chiefly to the diag- 
nosis of the affections just named. In this application, 
however, the associated signs must be taken into 
account. The vocal resonance may be diminished 
or suppressed when the lung is completely solidified 
in the second stage of pneumonia; also in pulmonary 
oedema, and over the site of an intra-thoracic tumor. 

If the vocal resonance be normal, that is, neither 
increased nor diminished, we are warranted in ex- 
cluding all the affections which have been named ; 



DIMINISHED VOCAL RESONANCE. 151 

the exceptional instances are so rare that, practically, 
they may be disregarded. 

Diminished vocal resonance may be found over a 
pulmonary abscess before the pus is evacuated, and 
over a cavity filled v^^ith liquid. The sign is then 
limited to a circumscribed space. Obstruction of a 
bronchial tube diminishes resonance in so far as the 
column of air is a medium for the conduction of 
vocal sound. 

The normal disparity between the two sides of the 
chest is to be borne in mind with reference to dim- 
inished or suppressed, as well as to increased, vocal 
resonance ; otherwise the relative feebleness of the 
resonance on the left side in health might be con- 
sidered to be morbid. The normally greater reso- 
nance on the right side renders it easier to determine 
a morbid diminution on this than on the left side. 

Diminished and Suppressed Vocal Fremitus. — This 
tactile sensation, which is appreciable in ausculta- 
tion, as a rule, is, on the one hand, increased, and, 
on the other hand, diminished or suppressed, under 
the same physical conditions which occasion corre- 
sponding modifications of the vocal resonance. 
Diminished or suppressed vocal fremitus, therefore, 
has the same diagnostic significance as diminished 
or suppressed vocal resonance. Usually the abnor- 
mal modifications of resonance and fremitus go 
together, but either may be out of proportion to the 
other. The signs relating to fremitus thus corrobo- 
rate those relating to resonance. The former may 
be marked when the latter admit of doubt. Dim- 
inished or suppressed fremitus is valuable in the 
diagnosis of pleurisy with effusion, empyema, hydro- 



152 AUSCULTATION IN DISEASE. 

thorax, and pneumothorax. It is, however, to be 
noted that in exceptional instances the fremitus 
persists over the site of liquid v^^ithin the chest. 

"With regard to vocal fremitus, as to vocal reso- 
nance, it is essential to take cognizance of the normal 
disparity between the two sides of the chest, the 
greater relative fremitus, on the right side, as a rule, 
being no less marked than the relatively greater 
resonance on that side. 

Metallic Tinkling. — This sign has the same char- 
acters when it accompanies either the loud or whis- 
pered voice, as when it is heard with respiration, 
and, of course, it has the same significance {vide 
page 99). It may be more marked with acts of 
speaking than with the respiratory acts. 

Signs obtained by Acts of Coughing or Tussive Signs. 

Acts of coughing may be made subservient to 
auscultation of respiratory sounds in two ways: 
F-irst, by the removal of temporary obstruction from 
the accumulation of mucus wnthin bronchial tubes. 
If the respiratory murmur be diminished or sup- 
pressed over a portion or the wdiole of one side of 
the chest, sometimes an act of coughing effects dis- 
lodgement of a mass of mucus from either a primary 
bronchus or one of its subdivisions, and the normal 
murmur is at once restored. The dependence of the 
morbid sign upon a temporary obstruction is thus 
demonstrated. Second^ by an act of coughing more 
air is expelled than by an ordinary expiration, and 
in the following inspiration the vesicles have a wider 
range of expansion, giving rise to a proportionately 
loud inspiratory sound ; hence, the characters of this 



COUGHING OK TUSSIVE SIGNS. 153 

sound are more pronounced and can be better studied. 
For these two objects it is often advisable to request 
the patient to cough with a certain degree of force. 

Acts of coughing, moreover, give rise to ausculta- 
tory signs which have their analogues in signs 
obtained bj respiration and the voice. These tussive 
signs are of less value than the respiratory and vocal 
signs, and in most cases, owing to the latter being 
sufficient for diagnosis, they may be said to be super- 
fluous; nevertheless, they may be observed some- 
times with advantage. When the conditions are 
present which are represented by bronchial respira- 
tion, bronchophony and the bronchophonic whisper, 
sounds are obtained which correspond to these in 
their characters. The cough is then said to be 
bronchial. With the stethoscope applied over an 
emptj^ cavity of some size, situated near the surface 
of the lung, the ear receives with acts of coughing a 
concussion or shock which is sometimes so forcible 
as to be painful. This corresponds to an intense 
vocal resonance. Limited to a circumscribed space, 
it is a highly significant cavernous sign. It may be 
present when the cavernous respiration is wanting. 
A low-pitched blowing sound corresponds to the ex- 
piratory sound in the cavernous respiration and the 
cavernous whisper. An amphoric intonation may 
be heard with acts of coughing, which corresponds 
to amphoric respiration and amphoric voice. This 
sign is sometimes more marked with cough than 
with the breathing and voice. Cavernous gurgling 
may also be obtained more distinctly with cough 
than with respiration. Finally, metallic tinkling 
not infrequently accompanies acts of coughing. 



CHAPTER VI. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
EESPIPvATOKY ORGANS. 

Affections of the larynx and trachea — Bronchitis seated in large bron- 
chial tubes — Bronchitis seated in small bronchial tubes, or capillary 
bronchitis — Collapse of jiulmonary lobules — Lobular pneumonia — ■ 
Asthma — Pulmonary or vesicular emphysema — Pleurisy, acute and 
chronic — Empyema —-Hydrothorax — Pneumothorax — Pneumohydro- 
thorax — Pneumo-pyothorax — Acute lobar pneumonia — Circumscribed 
pneumonia — Embolic pneumonia — Hemorrhagic infarctus — Pulmonary 
apoplexy — Pulmonary gangrene — Pulmonary oedema — Carcinoma of 
lung — Tumor within the chest — Acute miliary tuberculosis — Pulmonary 
phthisis — Fibroid phthisis, interstitial pneumonia, or cirrhosis of lung 
— Diaphragmatic hernia. 

In the preceding chapters the physical conditions 
incident to the morbid changes occurring in the 
aftections of the respiratory organs have been enu- 
merated, and the physical signs, obtained by per- 
cussion and auscultation, representing these condi- 
tions, have been considered, severally, as regards 
their distinctive characters and their signiiicance. 
The object of this chapter is to group the physical 
conditions embraced in the different diseases of the 
respiratory system respectively, together with the 
representative signs on which rests the physical 
diagnosis of each of the diseases. The scope of this 
manual is limited to the physical diagnosis of these 
affections ; but the fact is not to be lost sight of that 
in practical medicine physical signs are not to be 



AFFECTIONS OF LARYNX AND TRACHEA 155 

disassociated from symptoms and pathological laws. 
An exclusive reliance on physical signs would lead 
to errors in diagnosis, although, doubtless, errors 
more important and more frequent necessarily occur 
when the practitioner ignores percussion and auscul- 
tation. The signs furnished by percussion and 
auscultation only have been thus far considered, but 
in grouping these in this chapter, signs obtained by 
other methods of physical exploration will be em- 
braced in so far as they enter into the diagnosis of 
the difierent diseases of the respiratory system. 
These difierent diseases will be taken up separately 
with the exception of those seated in the larynx and 
trachea. With reference to phj^sical signs, the 
laryngeal and tracheal affections may be considered 
collectively. 

Affections of the Larynx and Trachea. 

The physical signs referable to the chest in dis- 
eases of the larynx and trachea, denote more or less 
obstruction to the free passage of air through these 
sections of the air-tubes. The obstruction in the 
different diseases involves different pathological 
conditions. Spasm of the glottis is one of these 
conditions, constituting the affections known as 
laryngismus stridulus and spasmodic croup, occur- 
ring also as a pathological element in laryngitis, and 
sometimes in connection with aneurism, or a tumor 
of some kind, involving the recurrent laryngeal 
nerve. Another pathological condition is the op- 
posite of this, namely, paralysis of the muscles of the 
glottis, the vocal chords remaining flaccid, and ap- 



156 PHYSICAL DIAGNOSIS 

proximating during inspiration. Other pathological 
conditions are, oedema of the glottis, swelling of the 
membrane at the glottis in laryngitis, together with, 
in the adult, submucous infiltration, diphtheritic 
exudation, cicatrization of ulcers, morbid growths, 
and the presence of foreign bodies. 

In the afl:ections involving the foregoing patholo- 
gical conditions, percussion and auscultation are of 
use, first, by enabling the physician to exclude all 
diseases within the chest. The absence of signs 
showing the existence of pulmonary diseases renders 
it certain that the symptoms denoting embarrassment 
of respiration are referable to the larynx or trachea. 
Second, by means of auscultation the amount of ob- 
struction may be determined more accurately than 
by the subjective symptoms. The amount of ob- 
struction is represented by a proportionate weakening 
of the vesicular murmur. This is more reliable as 
regards determining a dangerous amount of obstruc- 
tion than the sense of the want of air or the suffering 
of the patient. The degree of diminution of the 
vesicular murmur is determinable with the more 
accuracy the better the auscultator is acquainted 
with the normal intensity, that is, the intensity prior 
to the occurrence of obstruction. With this knowl- 
edge, the weakening of the murmur is a correct 
criterion of the amount of obstruction. In all the 
pathological conditions named, the respiratory mur- 
mur is more or less diminished in intensity on both 
sides of the chest; there are no signs obtained by 
percussion, nor do vocal resonance or fremitus otfer 
anything distinctive. 

In cases of considerable or great obstruction during 



BRONCHITIS IN LARGE BRONCHIAL TUBES. 157 

inspiration, inspection furnishes marked signs. The 
expansion of the chest on both sides is restricted, 
the lower part of the chest is contracted in the act 
of inspiration, and in this act the soft parts above 
the clavicles are depressed. The contrast between 
these abnormal movements and the normal thoracic 
movements of the patient is striking and distinctive. 
An important application of auscultation is the 
localization of a foreign body which has been inhaled. 
If the vesicular murmur on both sides be more or 
less weakened, the foreign body must be situated in 
either the larynx or the trachea. If, on the other 
hand, the vesicular murmur be weakened or sup- 
pressed on one side, and increased on the other side, 
the body is lodged in a primary bronchus. The 
importance of this application of auscultation before 
opening the trachea to remove a foreign body is 
sufficiently obvious. The situation of a foreign body 
may be changed from one bronchus to the other by 
an act of coughing, even after an operation has been 
commenced ; this is, of course, at once determinable 
by auscultation. 

Bronchitis Seated in Large Bronchial Tubes. 

In bronchitis, either acute or chronic, as it is ordi- 
narily presented in practice, the inflammation is 
seated in the large bronchial tubes, in many cases 
probably not extending beyond the primary and 
secondary bronchi. The physical conditions are, 
more or less swelling of the mucous membrane, this, 
however, not being sutficient to occasion any notable 
obstruction to the free passage of air, and the pres- 
ence, in different cases, in greater or less quantity, 
14 



158 PHYSICAL DIAGNOSIS. 

of mucus, rauco-purulent matter, pure pus, and 
serum. 

The physical diagnosis involves negative rather 
than positive points; in other words, the diseases 
from which bronchitis is to be diiFerentiated are ex- 
cluded by the absence of their diagnostic signs. 
These diseases are pneumonia, pleurisy, and phthisis. 
Each of these is characterized by the presence of 
signs, the absence of which warrants its exclusion. 
In bronchitis there is no disparity between the two 
sides of the chest in the resonance obtained by per- 
cussion, nor in vocal resonance, the bronchial whis- 
per, and fremitus. The swelling of the bronchial 
mucous membrane maj^ cause some diminution of 
the intensity of the vesicular murmur, but as the 
affection is bilateral, and the bronchial tubes on each 
side are affected equally, both in degree and extent, 
no appreciable disparity in this respect between the 
two sides is caused by this physical condition. 
Weakening or suppression of the murmur over an 
area greater or less, may be caused by bronchial 
obstruction from a plug of mucus. This obstruction 
is sometimes removed by an act of expectoration, 
after which the murmur is found to have returned, 
or to have regained its normal intensity. 

The foregoing points, taken in connection with 
the history and symptoms, suffice for the diagnosis. 
Signs due directly to the disease represent diminished 
calibre of the tubes at certain points from swelling 
of the membrane, adhesive mucus, and spasm of 
bronchial muscular fibres. These signs are the dry 
bronchial rales. They are rarely prominent, and 
are oftener absent than present, if the bronchitis be 



CAPILLARY BRONCHITIS. 159 

unaccompanied by asthma; hence, they are of little 
value in the diagnosis. Other signs are the bubbling 
sounds or the moist bronchial r^les. In acute bron- 
chitis these are oftener absent than present. They 
occur when liquid morbid products within the tubes 
are unusually abundant, or when the removal of 
these is with difficulty effected by expectoration in 
consequence of muscular debility or other causes. 
These rtles are abundant and loud in proportion as 
the liquid within the tubes is either muco-purulent, 
purulent, or serous in character. They are more or 
less coarse in proportion to the size of the tubes in 
which the bubbling takes place. 

The diagnostic points, negative and positive, which 
have been stated, are alike applicable to acute and 
chronic bronchitis, it being, of course, understood 
that the affection is primary, that is, not secondary 
to some other pulmonary disease. 

If the bronchitis be unaccompanied by solidifica- 
tion of lung, the moist rales which may be present 
are low in pitch. The pitch is raised if there be 
solidified lung surrounding or adjacent to the tubes 
in which the moist rales are produced. 

Bronchitis Seated in Small Bronchial Tubes — Capillary 
Bronchitis — Collapse of Pulmonary Lobules — Lobular 
Pneumonia. 

Inflammation extending into the small tubes 
(capillary bronchitis) occasions in these the same 
physical conditions which are incident to bronchitis 
affecting tubes of large size, namely, swelling of the 
membrane, and the presence of liquid morbid pro- 
ducts. The latter are not as easily removed by ex- 



160 PHYSICAL DIAGNOSIS. 

pectoration as when they are within large tubes, 
and, therefore, they are constantly present in greater 
or less quantity. These conditions in small tubes 
involve obstruction to the free passage of air to and 
from the air-vesicles ; hence, the vast difference as 
regards the symptoms, the suffering, and the danger. 
The affection is bilateral, a fact greatly enhancing 
the gravity of the affection. An incidental physical 
condition is solidification, generally in disseminated 
portions of lung, the latter varying in number and 
size. These portions of solidified lung denote either 
collapse of pulmonary lobules or lobular pneumonia, 
or both in conjunction. To this incidental affection, 
German writers apply the name " Catarrhal pneu- 
monia." Of course, any discussion of pathological 
questions suggested by these names would be here 
out of place. With reference to diagnosis it is to be 
borne in mind that the solidified portions of lung in 
cases of bronchitis seated in small tubes are espe- 
cially situated in the lower lobes. Another inci- 
dental physical condition is temporary dilatation of 
the air-cells, or vesicular emphysema, seated in the 
upper lobes. Both of these incidental conditions 
are bilateral, like the bronchitis with which they are 
connected. Collapse of pulmonary lobules, or lobu- 
lar pneumonia, or both, and emphysema occur in 
only a certain proportion of the cases of bronchitis 
seated in small tubes. Thp signs, therefore, admit 
of a division into those which relate, 1st, to the 
bronchitis, and, 2d, to these incidental affections. 
With reference to the diagnosis, the fact is to be 
borne in mind that bronchitis seated in small tubes 
occurs chiefly in children and the'aged. 



CAPILLARY BRONCHITIS. 161 

The pliysical diagnosis of bronchitis seated in 
small tubes rests on negative points, together with 
a positive sign which is uniformly present. This 
sign is the fine moist bronchial or the so-called sub- 
crepitant rale, present on both sides and diffused 
over the chest. The bubbling sounds are to be dis- 
tinguished from the fine dry crackling sounds or the 
crepitant rale, to the characters of which the former 
in some measure approximate. 

The bronchitis gives rise neither to dulness on 
percussion, nor to any notable change in vocal reso- 
nance, or fremitus. The respiratory murmur, if not 
obscured by rales, is weakened on both sides. Irre- 
spective of being drowned by rales, it may be sup- 
pressed by the amount of bronchial obstruction. 
These are the negative points in the diagnosis. In 
pulmonary cedema, fine moist bronchial rales are 
present on both sides, but in this affection there is 
notable dulness on percussion, and the affection 
occurs in certain pathological connections, namely, 
with mitral stenosis, and disease of the kidneys. 
Acute tuberculosis may present the moist bronchial 
rales with the negative points which, in connection 
with symptoms, characterize bronchitis seated in the 
small tubes. The differentiation is to be based on 
differences pertaining to the history and duration, 
together with the age of the patient. 

The coexistence of the incidental affections, 
namely, collapse of pulmonary lobules, or lobular 
pneumonia, and vicarious emphysema, occasions 
additional signs. If the solidified portions of lung 
be considerable in either number or size, there will 
be dulness on percussion in circumscribed situations 

14* 



162 PHYSICAL DIAGNOSIS. 

on the posterior aspect of the chest. This will be 
found on both sides, but perhaps more marked on 
one side. Broncho-vesicular or the bronchial respira- 
tion may be present, together with the vocal signs 
of solidification, namely, either increased vocal reso- 
nance, or bronchophony, and increased vocal fre- 
mitus. The moist rales produced within solidified 
portions of lung are high in pitch, whereas, if solidi- 
fication do not exist, these rtles are comparatively 
low in pitch. The existence of solidification at any 
point may be determined by the pitch of the rales, 
as well as by the foregoing respiratory and vocal 
signs. 

When there are emphysematous lobules on the 
anterior aspect of the chest in the upper and middle 
regions, on both sides, the resonance on percussion 
is vesiculo-tympanitic, the respiratory murmur weak- 
ened or suppressed, and the rhythm altered — in 
short, the combination of signs which will be stated 
under the head of emphysema. 

In the cases in which the bronchitis occasions 
great obstruction in the small tubes, and, still more, 
if collapse of lobules, or lobular pneumonia and 
vicarious emphysema occur, important signs are ob- 
tained by inspection. The anterior portion of the 
chest remains expanded, and retraction of the lower 
part of the chest takes place in the acts of inspiration. 

Asthma. 

The pathologico-physical condition in a paroxysm 
of asthma, is obstruction in the small bronchial 
tubes attributable to spasm of the bronchial muscu- 
lar fibres. With this condition is associated a tem- 



ASTHMA. 163 

porary vesicular emphysema, which exists often as 
a persistent aifection in persons who are subject to 
asthma. If the emphysematous condition already 
exist, it is increased during the paroxysm of asthma. 
Bronchitis generally coexists, either as a transient 
or a chronic affection. In an asthmatic paroxysm, 
therefore, there are present the signs which are 
proper to asthma, together with those of emphysema, 
and the associated bronchitis may also occasion ad- 
ditional signs. 

The physical diagnosis of asthma, like that of 
bronchitis seated in small tubes, is based on nega- 
tive points taken in connection with a sign which is 
invariably present, namely, dry bronchial rales. 
These rales are more or less intense, and they are 
diffused over the entire chest. They are generally 
heard at a distance. The sibilant and sonorous 
varieties are mingled, and they are constantly chang- 
ing as regards the character of the sounds. 

The negative points are the same as in capillary 
bronchitis, namely, absence of dulness on percussion, 
vocal resonance and fremitus also being unaltered. 
Asthma and bronchitis seated in small tubes agree 
in the fact that obstruction is the important physical 
condition. A highly important differential point 
relates to the frequency of the respirations; they 
are much increased in frequency in capillary bron- 
chitis, and not in asthma. Pathologically they differ 
essentially in the fact that the obstruction is due in 
the latter affection to bronchial inflammation, and 
in the former to spasm. The two affections differ 
in the signs representing these different conditions, 



164 PHYSICAL DIAGNOSIS. 

fine moist bronchial rales existing in one, and loud 
diffused dry bronchial rales existing in the other. 

Taking the difference as regards the positive 
physical signs in connection with the history and 
symptoms, the differentiation of the two affections 
may be made without difficulty. 

The signs which relate to the associated emphy- 
sematous condition are those which are diagnostic 
of this condition existing irrespective of asthma; 
and the physical diagnosis of emphysema will be 
next considered. Coexisting bronchitis may give 
rise to moist bronchial rales more or less coarse. 
These are, however, often wanting, and they are 
rarely marked during paroxysms of asthma. When 
present in this pathological connection, they are 
low in pitch, denoting the absence of solidification 
of lung. 

Pulmonary or Vesicular Emphysenia. 

This affection, as a rule, is seated exclusively or 
chiefly in the upper lobes. When it is lobar, in 
contradistinction from the emphysema existing in 
comparatively a few disseminated or isolated por- 
tions of lung, increase in volume of the affected 
lobes is an important physical condition standing in 
relation to certain signs. Diminished range of ex- 
pansion with acts of inspiration is another physical 
condition ; the affected lobes are in a permanent 
state of expansion approximating to that at the end 
of the inspiratory act. It follows from these condi- 
tions that the amount of air is in excess of the 
normal proportion to the solids and liquids in the 
affected lobes. Both lungs are affected, that is, the 



PULMONARY OR VESICULAR EMPHYSEMA. 165 

affection is bilateral. In the great majority of cases 
chronic bronchitis coexists, and patients affected 
with emphysema are often, but by no means invari- 
ably, subject to paroxysms of asthma. Not infre- 
quently an asthmatic element, with or without pro- 
nounced paroxysms of asthma, exists much of the 
time in connection with emphysema. The emphy- 
sematous condition, as a rule, with few exceptions, 
is greater in the upper lobe of the left than of the 
right lung. A rare condition, which is generally 
included under the name emphysema, differs mate- 
rially from the ordinary form of this affection. This 
condition is that also known as senile atrophy of the 
lungs. The volume of the lungs is not increased in 
this variety of emphysema, the proportion of air 
over the solids is, however, in excess, owing to the 
diminution of the latter from atrophy. 

The diagnostic evidence obtained by percussion is 
quite distinctive of lobar emphysema. The reso- 
nance over the upper and middle regions of the 
chest on both sides is vesiculo-tympanitic, that is, 
the intensity of the resonance is abnormally in- 
creased, the quality is a combination of the vesicular 
and tympanitic, and the pitch is more or less raised. 
Ovring to the fact that the emphysema is greater on 
the left than on the right side, the vesiculo-tympanitic 
resonance is more marked on the left side. The 
difference in intensity between the two sides may 
lead to the error of regarding the resonance on the 
right side as dulness. The error is avoided by at- 
tention to the pitch and the quality of the resonance. 
If dulness existed on the right side, the pitch of the 
sound should be higher on that side ; on the other 



166 PHYSICAL DIAGNOSIS. 

hand, if the cliiFerence in intensity be due to the 
greater amount of emphysema on the left side, the 
pitch is higher on that side, and the quality vesiculo- 
tympanitic. The attention of the student is particu- 
larly called to the foregoing points of distinction. 
Assuming that a vesiculo-tympanitic resonance 
exists anteriorly on both sides, and that it is marked 
on the left as contrasted with the right side, how is 
the existence of this sign on the right side to be de- 
termined? The answer is, the resonance over the 
upper is to be compared with that over the lower 
lobe of the right lung. Percussing first over the 
upper lobe of the right lung, and second over the 
lower lobe of this lung, that is, posteriorly, below 
the scapula, or in the infra-axillary region, the 
vesiculo-tympanitic resonance over the upper lobe is 
rendered manifest. In a series of patients afi:ected 
with emphysema, the uniformity of the results of 
percussion is very striking; anteriorly, over the left 
side, the resonance is vesiculo-tympanitic as com- 
pared with the resonance on the right side, and the 
resonance is shown to be vesiculo-tympanitic on the 
right side anteriorly as compared with the resonance 
posteriorly below the scapula. 

As regards the abnormal modifications of the 
respiratory murmur in emphysema, there is, Jimt, 
either weakened respiratory murmur without notable 
change in pitch or quality, or suppression of the 
murmur. Diminished intensity of the murmur 
exists over the upper lobes on both sides, as com- 
pared with the murmur over the lower lobes; and 
in most cases the greater diminution or the suppres- 
sion is on the left rather than on the right side. 



PULMONARY OR VESICULAR EMPHYSEMA. 167 

Exceptions to the latter statement may be caused by 
obstruction of the bronchial tubes on the right, and 
not on the left side, by an accumulation of mucus, 
and, in rare instances, by the fact that the emphy- 
sema is greater on the right side. Occasionally 
there is almost suppression below with preserved 
respiration above of the emphysematous type, and 
this so continuous as not to be explained by obstruc- 
tion of tubes. Second, modifications in rhythm are 
not infrequent. These consist in a shortened (de- 
ferred) inspiratory, and a prolonged expiratory 
sound. In some instances an inspiratory sound is 
wanting, and an expiratory sound is alone heard. 
The prolonged expiratory sound in emphysema is 
always low in pitch and blowing or non-tubular in 
quality, in these respects differing from the prolonged 
expiration which denotes solidification of lung, the 
latter being high in pitch and tubular in quality. 
These essential points of difference I claim to have 
been the first to have distinctly stated. 

The foregoing signs obtained by percussion and 
auscultation are those which are, in a positive sense, 
diagnostic of emphysema. Associated with these 
are certain important negative points, as follows : 
vocal resonance, vocal fremitus, and bronchial whis- 
per are not notably altered. These negative points 
suffice to exclude other affections than emphysema. 

Signs obtained by inspection are quite distinctive 
of this affection. Emphysema, existing in a marked 
degree, causes a characteristic deformity of the chest; 
the anterior surface is bulging, giving to the chest 
an abnormally rounded, bow-windowed, or barrel- 
shaped appearance, the lower part appearing to be 



168 PHYSICAL DIAGNOSIS. 

contracted. This deformity occurs wlien the em- 
physema has been developed in early life. The 
movements of the chest in inspiration are character- 
istic. In tranquil breathing there is but little move- 
ment of the upper and anterior regions, but in forced 
breathing the sternum and ribs move together as if 
they were one solid piece. The lower portion of the 
chest and the epigastrium are retracted in inspira- 
tion ;^ the costal angle is diminished, the ribs and 
cartilages connected with the sternum being some- 
times on a line ; the soft parts above the clavicle and 
sternum are often notably depressed with inspiration. 
Owing to depression of the heart downward and in- 
ward, the cardiac impulses are seen and felt in the 
epigastrium. Percussion and vocal resonance show 
the superficial cardiac region to be diminished or 
lost, the upper lobe of the left lung covering this 
space. There may be more or less anterior curva- 
iure of the spine, and the lower portions of the 
scapulfe may project, so that sometimes the plane of 
these bones is almost horizontal. These striking 
appearances characterize cases in which emphysema 
exists in a marked degree, and especially when the 
affection dates from early life. They are less marked 
or wanting if the emphysema be moderate in de- 
gree, and it have taken place in middle-aged per- 
sons or those advanced in years. 

In the variety of emphysema distinguished as 
senile, or senile atrophy of the lungs, in which there 
is coalescence of air-vesicles from destruction of the 

^ The retraction may be only apparent. Professor Janeway 
states that he has made measurements showing in some cases that 
there is no real retraction. 



PLEURISY, ACUTE AND CHRONIC. 169 

cell- walls without increased volume of the affected 
lobes, the diagnosis is to be based on the vesiculo- 
tympanitic resonance on percussion, weakened 
respiratory murmur, with, perhaps, the alterations 
in rhythm, sinking of the soft parts above the clavi- 
cles, and the negative points, exclusive of deformity 
of the chest, which have been described. 

Emphysema can hardly be confounded with any 
other affection than phthisis. The differentiation 
between these two affections is sufficiently easy if 
the diagnostic points, positive and negative, of the 
former, be appreciated. Phthisis occurring in a 
patient affected with emphysema makes a somewhat 
difficult problem in diagnosis; but, fortunately for 
the diagnostician, a patient with emphysema very 
rarely becomes phthisical. 

Owing to the frequency with which an asthmatic 
element enters into the clinical history of emphy- 
sema, the dry bronchial (sibilant and sonorous) rales 
are often present, even when paroxysms of asthma 
do not occur. 

Pleurisy, Acute and Chronic — Empyema — Hydrothorax. 

In the first stage of acute pleurisy — that is, prior 
to the effusion of liquid — the physical conditions 
are, the presence of more or less recently exuded, 
soft lymph upon the pleural surfaces, which are now 
in contact, and restrained movements of respiration 
on the affected side in consequence of the pain which 
they occasion. In the second stage, serous liquid 
accumulates within the pleural cavity, the quantity 
varying in different cases, sometimes, although 
rarely, filling the chest on the affected side. In 

15 



170 PHYSICAL DIAGNOSIS. 

proportion to the quantity of liquid the space over 
which the pleural surfaces are in contact is restricted, 
the movements of these surfaces over each other are 
limited, and the lung is condensed. In the third 
stage the quantity of liquid decreases, the space 
over which the pleural surfaces are in contact in- 
creases, and the compressed lung is more or less 
expanded. The lymph upon the pleural surfaces 
becomes more dense and adherent. The surfaces 
may become agglutinated by the intervening Ij^mph. 
Finally, in convalescence, permanent adhesions re- 
sult from the production or growth of areolar tissue. 

In subacute and chronic pleurisy there is the same 
series of physical conditions, the points of difference 
being, as a rule, a less amount of exudation, and a 
greater amount of effused liquid. The quantity of 
liquid in chronic pleurisy is often sufficient to com- 
press the lung into a small solid mass situated at 
the upper and posterior part of the chest, and to 
dilate the affected side. The heart is often removed 
from its normal situation. If the pleurisy be on the 
left side, the heart may be pushed laterally beyond 
the right margin of the sternum; if the pleurisy be 
on the right side, the heart is pushed laterally to the 
left of its normal situation. 

In empyema the accumulation of pus is apt to be 
still greater than that of serous effusion in simple 
chronic pleurisy, causing, of course, greater dilata- 
tion of the chest, and more displacement of the 
heart. 

In these varieties of pleurisy the affection, with 
rare exceptions, is unilateral. 

In hydrothorax the conditions differ, first, as re- 



PLEURISY, ACUTE AND CHRONIC. 171 

gards the absence of the exudation of lymph; second, 
the affection is bilateral, the eff'usion of liquid taking- 
place in both pleural cavities; and, third, although 
the quantity of liquid may be considerably greater 
on one side, the accumulation very rarely, if ever, is 
sufficient to cause much dilatation of the chest on 
that side, with complete condensation of the lung, 
and notable displacement of the heart. 

The signs in the first stage of acute pleurisy are 
relative feebleness of the respiratory murmur on the 
affected side, from the restrained respiratory move- 
ments on that side, and a rubbing friction-sound. 
The former is not distinctive of pleurisy, being 
present when the respiratory movements on one side 
are restrained by pain in intercostal neuralgia and 
pleurodynia, A friction-sound is not always ob- 
tained. In the absence of this sound the physical 
diagnosis cannot be made with positiveness prior to 
the eff'usion of liquid. Assuming that the general 
and local symptoms point to an acute inflammatory 
affection, the diffierential diagnosis relates to pleurisy 
and pneumonia. A pleural friction-sound may be 
present in the latter as well as the former of these 
two affections. The pathognomonic sign of pneu- 
monia, the crepitant rale, being wanting, the diifer- 
entiation, in this stage, must rest on diagnostic 
points pertaining to the symptoms.^ 

In the second stage of acute pleurisy the diag- 
nostic signs are those which denote the presence of 

* Professor Janeway states that he has sometimes heard a crepi- 
tant rale at the inception of pleurisy, without coexisting pneu- 
monia. The mechanism in these instances is the same as in 
pneumonia. 



172 PHYSICAL DIAGNOSIS. 

liquid within the pleural cavity. These signs are 
simple and distinctive. There is either dulness or 
flatness on percussion at the base of the chest, ex- 
tending upward a distance proportionate to the 
quantity of liquid. If the trunk be in a vertical 
position — that is, the patient sitting or standing — 
the line of demarcation between the duhiess or flat- 
ness and pulmonary resonance is, or approximates 
to, a horizontal line on the anterior aspect of the 
chest. This line denotes the level of the liquid, and 
is easily obtained by percussion. It is as easily de- 
termined by auscultating the vocal resonance, this 
either abruptly ceasing or being notably diminished 
at the level of the liquid. Having ascertained the 
line forming the upper boundary of dulness or flat- 
ness on the anterior aspect of the chest, the patient 
sitting or standing, if the position be changed to 
recumbency on the back, and the pulmonary reso- 
nance be found then to extend more or less below 
this line, this fact is demonstrative proof of the pres- 
ence of liquid. Proof in this way is obtained in a 
large majority of cases, the exceptional cases being 
those in which the pleural surfaces are united, either 
by agglutination or permanent adhesions, above the 
level of the liquid.^ The resonance on percussion 
over the lung above the level of the liquid is gener- 

1 The statement with regard to a horizontal line denoting the 
level of the liquid does not apply to the posterior aspect of the 
chest. Observations show that posteriorly the lung extends more 
or less downward near the spinal column, and that the level of the 
liquid forms a curve which may be represented by the letter S. 
Vide article by Professor G. M. Garland, in the New York Medical 
Journal, number for November, 1879. Also treatise on " Pneumo- 
Pynamics," by Professor Garland, 1878. 



PLEURISY, ACUTE AND CHRONIC 173 

ally vesiculo-tympaiiitic — the intensity increased, the 
pitch raised, the vesicular and the tympanitic quality 
combined. Sometimes there is so little vesicular 
quality in this vesiculo-tympanitic resonance, that it 
may seem to be purely tympanitic, and is suggestive 
of pneumothorax. Associated, signs will always 
prevent this error of observation. As a rule, vocal 
resonance and fremitus are either notably lessened 
or suppressed over the portion of the chest situated 
below the level of the liquid. There are occasional 
exceptions to this rule. The respiratory sound below 
the level of the liquid is suppressed. If any be heard, 
it is transmitted either from the lung above the 
liquid, or laterally, from the lung on the other side 
of the chest. Above the liquid the respiratory 
sound, as a rule, is weakened. If the amount of 
liquid be sufficient to produce much condensation 
of lung, the respiratory sound is broncho- vesicular. 
Sometimes, owing to the pleural surfaces above 
being adherent, a strip of lung at the level of the 
liquid is sufficiently condensed by compression to 
give a bronchial respiration. Under these circum- 
stances, there will be either bronchophony or the 
modification of that sign known as segophony. If 
the lung be not sufficiently compressed for the pro- 
duction of these signs of solidification, the vocal 
resonance is simply more or less increased. The 
fremitus is usually increased above the liquid. Over 
the unaffected side the respiratory murmur is in- 
creased in intensity. 

The foregoing signs are present when the pleural 
cavity is partially filled; a quarter, a half, or two- 
thirds of the thoracic space being occupied by liquid. 
15* 



174 PHYSICAL DIAGNOSIS. 

The signs present when the cavity is completely 
filled will be presently stated in connection with 
chronic pleuris3\ 

The signs which have been stated show not only 
the presence of liquid but its quantity. By means 
of these signs are readily ascertained the progressive 
increase or decrease in the quantity of liquid, and 
its disappearance. After the liquid has disappeared, 
often notable dulness on percussion remains for some 
time, showing the presence of lymph not yet ab- 
sorbed. During the decrease of the liquid, and after 
its disappearance, a friction-murmur is often per- 
ceived. This murmur is now apt to be rough — a 
rasping, grating, or creaking sound. It may be loud 
enough to be heard by the patient, and by others at 
a distance from the chest. It continues sometimes 
for a considerable period. 

The physical diagnosis in cases of chronic pleurisy, 
when the liquid occupies a portion only of the tho- 
racic space, rests, of course, on precisely the same 
signs as in cases of acute pleurisy. If, however, the 
chest on the afit'ected side be filled and dilated, cer- 
tain of the signs which have been stated are want- 
ing, and others are added. The affected side is 
everywhere flat on percussion. Flatness on percus- 
sion over the whole of one side, the affection being 
chronic, denotes, as a rule, with rare exceptions, 
either chronic simple pleurisy or empj^ema. Respira- 
tory sound is wanting except at the summit over or 
near the compressed lung, where it is bronchial. 
Some cases offer an important exception to this rule, 
namely, the bronchial respiration is diffused over 
the greater part, or even the whole, of the affected 



PLEURISY, ACUTE AND CHRONIC. 175 

side. The student should bear in mind this fact; 
otherwise the diffusion of the bronchial respiration 
may lead to the suspicion that the flatness on per- 
cussion denotes solidifi-cation of lung and not the 
presence of liquid. Other signs, however, should 
always correct this error. Yocal resonance and 
fremitus are, with some exceptions, either suppressed 
or notably diminished over the whole of the affected 
side. Generally, even when the chest is not dilated, 
the intercostal depressions are lessened or abolished. 
If the walls of the chest be thinly covered with in- 
tegument, the two sides present a marked contrast 
in this respect. This is seen especially at the middle 
and lower regions of the chest anteriorly and later- 
ally. It is especially marked at the end of the in- 
spiratory act. If the affected side be dilated, this 
is apparent on inspection, and may be determined 
accurately by semicircular or diametric mensuration, 
calipers being required for the latter. The respira- 
tory movements on the affected side are diminished 
or annulled, and they are increased on the healthy 
side, the two sides affording a marked contrast in 
this regard. If the pleurisy be on the left side, the 
impulses of the heart are not infrequently felt on 
the right of the sternum. If the impulses cannot 
be felt, auscultation shows the maximum of the in- 
tensity of the heart-sounds to be more or less removed 
to the right. If the pleurisy be on the right side, 
the impulses or sounds of the heart denote more or 
less displacement laterally to the left. The intensity 
of the respiratory murmur on the unaffected side is 
notably increased. 

In cases of empyema the same signs are present 



176 PHYSICAL DIAGNOSIS. 

as in chronic pleurisy. The character of the liquid 
does not alter appreciably any of the signs which 
have been stated. Dilatation of the affected side of 
the chest is more apt to occur, and to be more 
marked than in simple pleurisy. The differential 
diagnosis between these two varieties of pleurisy is 
to be made with positiveness by the introduction of 
the needle of a hypodermic syringe having good 
suction force, previously cleaned and carbolized, 
and obtaining enough of the liquid to ascertain its 
character. 

When the left pleural cavity is tilled with pus, the 
movements of the heart sometimes give to the 
affected side of the chest an impulse perceived by 
the eye and touch; hence the term, pulsating em- 
pyema. After a spontaneous perforation of the 
chest, followed by a circumscribed purulent collec- 
tion beneath the integument, communicating with 
the pus within the pleural cavity, the tumor thus 
formed sometimes has a strong pulsation which is 
synchronous with the ventricular systole, and may 
give rise to the suspicion of aneurism. 

In cases of hydrothorax, the signs denote partial 
filling of the chest on both sides. The affection is 
bilateral. Generally the quantity of liquid in the 
two sides is not equal, and there is often a notable 
disparity in this respect. Friction-sounds are never 
present. Variation of the level of the liquid with 
change of the position of the patient from the ver- 
tical to the horizontal, is nearly always determinable. 
Hydrothorax, meaning by this term a purely dropsi- 
cal affection, is to be differentiated from double 
pleurisy with effusion. The history and symptoms. 



PNEUMOTHORAX. 177 

taken in connection with the signs, suffice for this 
discrimination. 

Pneumothorax — Pneumo-hydrotliorax — Pneumo- 
pyothorax. 

In the extremely rare cases of pneumothorax, that 
is, as distinguished from pneumo-hydrothorax and 
pneumo-pyothorax, the physical conditions are: the 
presence of air partially or completely occupying the 
thoracic space, and condensation of lung in propor- 
tion to the space occupied by air. 

The diagnostic signs are, a purely tympanitic 
resonance over a portion or the whole of the afiected 
side of the chest: suppression of the vesicular mur- 
mur over a space corresponding to that in which 
tympanitic resonance is obtained, with notable dim- 
inution or suppression of vocal resonance and fre- 
mitus. Over the compressed lung, if the condensation 
amount to complete or considerable solidification, 
there will be bronchial respiration and bronchophony; 
if the solidification be neither complete nor consider- 
able, there will be broncho-vesicular respiration with 
increased vocal resonance and fremitus. The accu- 
mulation of air may be sufficient to dilate the afifected 
side, and to restrain or annul the respiratory move- 
ments on this side. The appearances on inspection 
are then precisely the same as in the cases of chronic 
pleurisy and empyema in which the affected side is 
dilated from the presence of liquid. Pneumothorax 
is, however, at once differentiated by the tympanitic 
resonance on percussion. If one side of the chest be 
more or less dilated, and the resonance over the side 
be purely tympanitic, the thoracic space must be 



178 PHYSICAL DIAGNOSIS. 

filled, not with liquid but with air. The intensity 
of the respiratory murmur on the healthy side is 
increased. 

In the great majority of cases in which the pleural 
cavity contains air, there is also present more or less 
liquid, which may be serous or purulent. The affec- 
tion is then known as pneumo-hydrothorax if the 
liquid be serous, and pneumo-pyothorax if it be 
purulent. The physical conditions are the same as 
in pneumothorax, with the addition of the presence 
of liquid. The relative proportions of liquid and air 
in different cases are variable, and, also, in the same 
case at different periods. 

The physical diagnosis of pneumo-hydrothorax 
and of pneumo-pyothorax, as distinguished from 
pneumothorax, embraces the signs of liquid, in addi- 
tion to those of air, within the pleural cavity. If 
the quantity of liquid be large or considerable, per- 
cussion at the base of the chest gives flatness extend- 
ing upward more or less, and tympanitic resonance 
above, the patient either sitting or standing. A 
change from the vertical to the horizontal position 
invariably causes variation of the upper limit of the 
flatness, inasmuch as the liquid and air change their 
relative situations without an exception. The quan- 
tity of liquid is determined approximatively by ascer- 
taining the space over which the flatness on percus- 
sion extends. The line which divides the flatness 
and the tympanitic resonance does not accurately 
denote the level of the liquid, because tympanitic 
resonance is transmitted a certain distance below 
this level, hence it is always to be assumed that the 



ACUTE LOBAR PNEUMONIA. 179 

level of the liquid is somewhat higher than the upper 
boundarj' of the flatness. 

In either pneumothorax, pneumo-hydrothorax, or 
pneumo-pyothorax a group of auscultatory signs is 
often found which are highly diagnostic, indeed 
almost pathognomonic. These signs are amphoric 
respiration, amphoric voice or echo, and metallic 
tinkling. The amphoric and the tinkling sounds 
may be present, either without the other, but they 
are not infrequently associated. ^Neither are present 
in every case, and they are not present in the same 
case at all times ; their absence, therefore, by no 
means excludes the afl'ections, and they are not 
essential to the diagnosis. When present they de- 
note either air or air and liquid in the pleural cavity 
with perforation of lung or a large phthisical cavity. 
Their occurrence in the latter is comparatively rare, 
and whenever they are associated with other signs 
already stated, their diagnostic import is demonstra- 
tive. 

Pneumo-hydrothorax or pneumo-pyothorax may 
almost invariably be diagnosticated instantly by the 
presence of a succussion sound. Whenever distinct 
splashing is produced by succussion and referable to 
the chest, that is, not produced within the stomach, 
it is demonstrative of the presence of air and liquid 
within the pleural cavity. 

Acute Lobar Pneumonia. 

In the first stage of this disease there is an abnor- 
mal accumulation of blood within the vessels of the 
affected lobe (active congestion or hypersemia), with 
some exudation within the air-vesicles and bronchi- 



180 PHYSICAL DIAGNOSIS. 

oles. Generally there is some exuded lymph upon 
the pleural surface, this being- due to circumscribed 
dry pleurisy. In most cases there is also circum- 
scribed bronchitis, which is limited to the tubes 
within the aifected lobe. In the second stage there 
is solidification due to the increase of exudation 
within the air-vesicles. The solidification, at first 
limited, extends either rapidly or slowly, as a rule, 
over the whole lobe. Exceptionally more or less 
liquid efi'usion into the pleural cavity takes place 
(pleuro-pneumonia), the pleurisy then extending be- 
yond the limits of the affected lobe. In this stage 
the pneumonia may involve either another lobe of 
the lung primarily afifected, or a lobe of the opposite 
lung, and sometimes the disease, by successive inva- 
sions, extends over the whole of one lung, together 
with a lobe of the opposite lung. The pneumonia, 
in these secondary invasions, is usually accompanied 
by pleurisy and bronchitis. In the stage of resolu- 
tion the solidification of the affected lobe or lobes 
decreases, sometimes rapidly and sometimes slowly, 
until the normal condition is restored. If resolution 
do not take place, and the disease pass into the stage 
of purulent infiltration, the air-vesicles and bronchial 
tubes contain a puruloid liquid in greater or less 
quantity. Exceptionally pus is collected in a cavity, 
or in cavities, constituting pulmonary abscess. 

The physical diagnosis of acute lobar pneumonia 
in the first stage must be based on the presence of 
the crepitant rale, with moderate or slight dulness 
on percussion over the afifected lobe. There is some- 
times in this stage a pleuritic rubbing sound over 
the afifected lobe. The crepitant rale is not always 



ACUTE LOBAR PNEUMONIA. 181 

present, and hence the affection cannot be excluded 
by the absence of this sign. When present, taken 
in connection with the symptoms, this sign is pathog- 
nomonic of the disease. It is important not to mis- 
take for this sign fine bubbling or the subcrepitant 
rSle. When the crepitant rale is wanting, a positive 
physical diagnosis must be deferred until more or 
less of the affected lobe becomes solidified, that is, 
when the disease passes into the second stage. 

The diagnosis in the second stage is to be based 
on the signs of solidification furnished by ausculta- 
tion and percussion. The auscultatory signs are the 
broncho-vesicular, followed by the bronchial respi- 
ration ; increased vocal resonance, followed by bron- 
chophony, and increased bronchial whisper, followed 
by whispering bronchophony. The signs of solidi- 
fication are manifest at first within a circumscribed 
space, situated over either the upper, the lower, or 
the middle portion of the affected lobe, and either 
rapidly or slowly the signs extend in most cases 
over the entire lobe. The crepitant rale, if it have 
been present in the first, generally disappears in the 
second stage. Sometimes, however, it is not en- 
tirely lost in this stage. The broncho-vesicular 
respiration, increased vocal resonance, and increased 
bronchial whisper are present when the solidifica- 
tion is slight or moderate ; the bronchial respira- 
tion, bronchophony, and bronchophonic whisper 
take their place when the solidification becomes 
considerable or complete. The latter signs, as a 
rule, speedily follow, inasmuch as the solidification 
in most cases quickly becomes complete or con- 
siderable. The foregoing three signs, denoting 



182 PHYSICAL DIAGNOSIS. 

considerable or complete soliclilication, are usually 
present. Bronchial respiration, however, is some- 
times present without bronchophony, and vice versa. 
Either, present alone, suffices to show the existence 
and the extent of the solidilication. Moist bron- 
chial or bubbling rales are sometimes, but rarely, 
heard over the affected lobe. 

There is notable dulness on percussion in the 
second stage. The dulness may approximate and 
even amount to flatness. If a single lobe be af- 
fected, the dulness or flatness extends over a space 
corresponding to that occupied by the lobe or the 
portion of it which is solidifled. In the antero- 
lateral aspects of the chest, the dividing line be- 
tween the solidifled and the healthy lobe is readily 
ascertained by percussion, and this line is coincident 
with the interlobar fissure.^ It sometimes happens 
that the upper and the lower lobe of the right lung 
are affected, the middle lobe not becoming involved. 
The space corresponding to the middle lobe may 
then form an island of resonance surrounded by 
notable dulness on percussion. 

Whenever one lobe of a lung is affected, the reso- 
nance over the unaffected part of the same lung is 
abnormally increased, the pitch is raised, and the 
quality is vesiculo-tympanitic ; vesiculo-tympanitic 
resonance, in other words, is produced. This 
renders more marked the contrast between dulness 

' With reference to the localization of pneumonia in the upper 
or lower lobes the situations of the interlobar fissures on the an- 
terior, posterior, and lateral aspects of the chest are to be kept in 
mind, vide Figs. 1 and 2, pages 36 and 37. 



ACUTE LOBAR PNEUMONIA. 183 

over the solidified, and resonance over the healthy, 
lobe. 

Over a portion of an upper lobe in the second 
stage, instead of notable dulness or flatness, there 
may be marked tympanitic resonance. This reso- 
nance proceeds from air within the trachea and the 
bronchi exterior to the lungs, the lung substance 
being completely solidified ; it is chiefly or espe- 
cially marked over the site of these air-tubes. In 
some cases the tympanitic resonance has either the 
cracked-metal or the amphoric intonation. These 
signs, fer se, might suggest either pneumothorax or 
phthisical cavities; the associated respiratory and 
vocal signs, however, show only solidification of 
lung. In cases of pneumonia afifecting the left 
lung, a tympanitic resonance is not infrequently 
propagated from the stomach more or less upward 
over the affected side of the chest. This may be 
readily traced to the stomach. On the right side, a 
tympanitic resonance is sometimes propagated a 
certain distance upward from the transverse colon. 

The commencement of the stage of resolution is 
denoted by a broncho-vesicular respiration. The 
first change observed is the presence of a little 
vesicular quality in the inspiratory sound. When 
this is observed, the respiration is no longer bron- 
chial, but has become broncho-vesicular, although 
the pitch is still high, and the expiration is pro- 
longed, high, tubular. This slight change shows 
that air begins to enter the pulmonary vesicles. As 
resolution goes on, more and more of the vesicular 
takes the place of the tubular quality in the inspira- 
tory sound, and the pitch is lowered in proportion ; 



184 PHYSICAL DIAGNOSIS. 

the expiratory sound becomes proportionately less 
and less prolonged, its pitch lowered, its quality 
less tubular, until, at length, the normal characters 
of the respiratory murmur are regained. Resolu- 
tion is then complete. 

While the broncho-vesicular respiration is under- 
going the modifications just stated, the vocal sounds 
have corresponding changes. Bronchophony per- 
sists for some time after the respiration has become 
broncho-vesicular, and then disappears, increased 
vocal resonance generally taking its place and per- 
sisting until resolution is completed. The bronchial 
whisper loses its bronchophonic characters and is 
simply increased until its normal characters are re- 
gained. While the solidification is complete, the 
vocal fremitus may, or may not, be increased. It is 
sometimes diminished. When, however, resolution 
has so far progressed that bronchophony is lost, the 
fremitus is usually greater than in health, and so 
continues, but progressively lessening until the 
solidification entirely disappears. 

During the progress of resolution, the dulness on 
percussion diminishes in proportion as air enters 
the air-vesicles. If tympanitic resonance have been 
present over the upper lobe, this gives place to a 
vesicular resonance. Some dulness, however, re- 
mains after the completion of resolution, and 
persists until the exuded lymph on the pleural 
surface is absorbed. The amount of dulness re- 
maining when the respiratory and vocal signs de- 
note resolution, is proportionate to the quantity of 
exudation incident to the associated pleurisy. 

In this stage the crepitant rale not infrequently 



ACUTE LOBAR PNEUMONIA. 185 

returns, if it have entirely disappeared during the 
second stage, and if it have persisted, it is more 
marked and diffused. It is now known as the re- 
turning crepitant rale. More frequently the rale 
in this stage is a line bubbling or the so-called sub- 
crepitaut. Both rales are not infrequently associ- 
ated, and, from the distinctive characters of each, 
they are readily distinguished. Moist rales more or 
less fine or coarse are not infrequent. The pitch of 
these rales remains more or less high until the solidi- 
fying exudation is completely absorbed. 

If the affection pass into the stage of purulent in- 
filtration, the respiratory sounds are feeble or sup- 
pressed, having, if present, more or less of the 
bronchial characters. Bubbling bronchial rales, 
coarse and fine, are abundant. Weak broncho- 
phony may persist, or the vocal resonance may be 
diminished. Fremitus may, or may not, be in- 
creased. IsTotable dulness or flatness on percussion 
remains. 

If the pneumonia result in pulmonic abscess, 
there will be notable dulness or flatness on percus- 
sion within a circumscribed space, together with 
absence of respiratory murmur, and diminished or 
suppressed vocal resonance. These signs warrant 
a probable diagnosis w^hich is corroborated by the 
sudden expectoration of pus in a considerable quan- 
tity. The signs just stated may then be follow^ed 
by those denoting a cavity, namely, cavernous respi- 
ration and whisper, with intense vocal resonance. 



16* 



186 PHYSICAL DIAGNOSIS. 

Circumscribed Pneumonia — Embolic Pneumonia— Hemor- 
rhagic Infarctus or Pulmonary Apoplexy. 

The form of pneumonia known as lobular pneu- 
monia, occurring chiefly in children, has been con- 
sidered {vide Bronchitis seated in small-sized tubes). 
Whenever circumscribed, as a rule, pneumonia is 
secondary to some other pulmonary afl:ection. Cir- 
cumscribed pneumonia, giving rise to an intra- 
vesicular exudation which may disappear readily by 
resolution or absorption, is not very infrequent in 
cases of phthisis. The signs are those which repre- 
sent solidification of lung within an area more or 
less circumscribed ; but the diiierentiation from the 
solidification proper to phthisis can only be made 
with positiveness after the signs have shown that 
the solidification has notably diminished or disap- 
peared. 

In embolic pneumonia there may be dulness on 
percussion, with feeble bronchial or broncho-vesicu- 
lar respiration, or suppression of respiratory sound, 
weak bronchophony or increase of vocal resonance, 
within a circumscribed space, or within spaces, 
generally on the posperior aspect of the chest, and 
oftenest on the right side. These signs, taken in 
connection with the symptoms and pathological con- 
ditions which are consistent with the supposition of 
emboli received into the right side of the heart, 
namely, when the pulmonary symptoms follow puer- 
peral disease, ulcers, wounds, injuries, or venous 
thrombosis, render the diagnosis quite positive. If, 
however, the pulmonary afi'ection consist of small 
disseminated nodules, the foregoing signs will not 



PULMONARY GANGRENE. 187 

be present. The diagnosis then must be based on 
the history and symptoms, taken in connection with 
the exclusion of other pulmonary affections by the 
absence of signs which should be present if they ex- 
isted. Bubbling rales, the pitch more or less raised, 
at different situations may indicate the probable 
sites of the nodules. There may be pleuritic friction- 
sounds. The signs may show, as a complication, 
pleurisy with effusion. 

Extravasation of blood (pneumorrhagia), if it be 
in small spaces, gives rise to no deiinite physical 
signs. If, however, extravasation extend over a 
considerable space, there will be dulness on percus- 
sion, with feeble or suppressed respiratory sound 
within an area corresponding to the extent of the 
extravasation. Within, and near this area, there 
will be likely to be moist bronchial rales more or 
less tine or coarse. 

Pulmonary Gangrene. 

In diffused pulmonary gangrene the physical signs 
are those of solidification extending over the greater 
part or the whole of a lobe. The diagnosis, how- 
ever, can only be made when, in connection with 
these signs, there are present the characteristic fetor 
of the breath and expectoration. 

In circumscribed gangrene there is dulness or flat- 
ness on percussion within an area corresponding to 
the extent of the affection, with either suppression 
of respiratory sound or bronchial respiration, and 
the vocal signs of solidification. Within and near 
this space moist bronchial rales, more or less raised 
in pitch, are likely to be heard. The situation is 



188 PHYSICAL DIAGNOSIS. 

usually on the posterior aspect of the chest. These 
signs do not suffice for a positive diagnosis without 
the characteristic breath and expectoration. Cavern- 
ous signs may appear after the gangrenous portion 
of lung has sloughed away and been expectorated. 

Pulmonary (Edema. 

The physical condition expressed by the term pul- 
monary ojdema is the presence of effused serum 
within the air-vesicles. With this condition is asso- 
ciated more or less pulmonarj^ congestion. 

In cases of pulmonary oedema developed rapidly 
and largely in connection with renal disease, with 
obstruction at the mitral orifice of the heart, or with 
both these affections combined, giving rise to great 
dyspnoea, and liable to end speedily in death, the 
following are the diagnostic signs : Dulness on per- 
cussion on both sides of the chest, especially over the 
lower lobes, fine bubbling or so-called subcrepitant 
rales diffused over the chest on both sides, together 
with coarser bubbling sounds, and the murmur of 
respiration notably weak or suppressed over the 
lower lobes. Inasmuch as the lungs are not solidi- 
fied the rsiles are low in pitch. The vocal signs of 
solidification are, of course, wanting. Occasionally 
the crepitant rale is mingled with the fine bubbling 
sounds. 

This form of the affection is to be difierentiated 
from hydrothorax with large effusion, and from so- 
called capillary bronchitis. Hydrothorax is always 
associated with more or less anasarca, or general 
dropsy, whereas, pulmonary oedema, even when de- 
pendent on renal disease, may occur without drop- 



PULMONARY (EDEMA. 189 

sical eflusion elsewhere. Moreover, the presence of 
liquid within the pleural cavities, and its amount, 
may always be determined demonstratively in cases 
of hydrothorax (vide Pleurisy with effusion and Hy- 
drothorax). Capillary bronchitis occurs chiefly in 
children. The so-called subcrepitant rale on both 
sides of the chest is the diagnostic sign of this affec- 
tion, but it is not accompanied by dulness on per- 
cussion, except in so far as the bronchitis may be 
associated with lobular pneumonia or collapse of 
pulmonary lobules. The rapid development of the 
oedema and its pathological connections, are diag- 
nostic points to be taken into account. 

Pneumonia is excluded by the fact that the affec- 
tion is at the beginning bilateral, and by the absence 
of the signs of solidification of lung. 

Pulmonary oedema less in degree and diffusion, 
has, of course, the same signs, not as marked and 
not as extensive, namely, dulness on percussion and 
fine bubbling sounds or the so-called subcrepitant 
rales. In this form the affection is bilateral, and 
seated especially in the posterior and inferior por- 
tions of the lungs. Moreover, this form has the 
same pathological connections, namely, with disease 
of the kidneys, and mitral lesions of the heart. The 
low pitch of the bronchial rales, and the absence of 
the respiratory and vocal signs of solidification, to- 
gether with the fact of the affection being bilateral, 
and the coexistence of disease of the heart or kidneys, 
constitute the basis of a positive diagnosis. 

Hypostatic congestion of the lungs may occasion 
a certain amount of pulmonary oedema. The physi- 
cal diasrnosis is to be based on bilateral dulness on 



190 PHYSICAL DIAGNOSIS, 

the posterior aspect of the chest, with low-pitched, 
fine bubbling sounds, or the so-called subcrepitant 
rales on both sides, these signs occurring under 
circumstances which lead to the supposition of this 
form of congestion. 

Carcinonia of Lung — Tumors within the Chest. 

Carcinomatous growths in the lungs are usually 
in the form of nodules varying in size from that of 
a pea to a hen's egg, disseminated throughout one 
lung or both lungs, in greater or less numbers. 
These disseminated nodules, if of small size, have 
no well-marked, definite diagnostic signs. If limited 
to a lung, or if greater in number in one lung, they 
may occasion an appreciable dulness on percussion. 
They may also occasion feebleness of the respiratory 
murmur, and, owing to coexisting circumscribed 
bronchitis, moist bronchial rales may be heard at 
different points. These signs warrant a diagnosis 
when, as is usually the case, cancer is known to 
have existed elsewhere. With reference to diagnosis, 
it is to be borne in mind that, when cancer of the 
lung is secondary, both lungs are affected, and, when 
it is primary, the affection is generally unilateral. 

If there be nodules of considerable size, there will 
be well-marked dulness on percussion in different 
situations, and the signs of solidification may be 
present, namely, either bronchial or broncho-vesicular 
respiration, either increased vocal resonance or 
bronchophony, and increased vocal fremitus. 

In some cases of unilateral carcinoma, the greater 
part, or the whole, of a lung may be infiltrated with 



CARCINOMA OF LUNG. 191 

the morbid growth, increasing its volnme and giving 
rise to enlargement of the affected side, diminished 
respiratory movements or immobility, flatness on 
percussion, with diminished or suppressed respira- 
tory murmur, vocal resonance, and fremitus. If, as 
is usual, there be also more or less pleuritic effusion, 
the intercostal spaces may be pushed out to a level 
with the ribs. Here are the signs which denote 
chronic pleurisy wath large effusion, and the differ- 
ential diagnosis cannot be made with positiveness 
until the fluid within the chest be withdrawn, and it 
be found that, irrespective of the bulging of the 
intercostal spaces, the physical signs remain. Ex- 
ploration with a small trocar, or hollow^ needle, will 
settle the diagnosis wdien there is no pleuritic effu- 
sion, and this procedure is unobjectionable. 

In other cases the carcinomatous growth induces 
atrophy of the lung, diminishing its volume, and 
causing notable contraction of the affected side. The 
appearances on inspection are those which denote 
contraction after chronic pleurisy, and they may be 
present also in cases of fibroid phthisis or cirrhosis 
of lung. The differential diagnosis must be based 
chiefly on diagnostic points relating to the history 
and symptoms. 

Tumors within the chest, generally having their 
points of departure in the mediastinum, displace the 
lung in proportion to their size. They may cause 
considerable displacement of the heart, and produce 
more or less enlargement of the chest with dimin- 
ished respiratory movements. Enlargement of the 
subcutaneous veins, indicative of venous obstruction, 
is often to be observed. Over the site of the tumor, 



192 PHYSICAL DIAGNOSIS. 

there will be either dulness or flatness on percussion. 
Generally respiratory sound is wanting, vocal reso- 
nance and fremitus being either diminished or sup- 
pressed. In the neighborhood of the primary 
bronchi and over lung compressed by the tumor, 
there may be bronchial respiration, with broncho- 
phony and increased fremitus. If the chest be en- 
larged, its enlargement is not likely to be as uniform 
as wheti it is dilated with liquid; this is a diagnostic 
point. The tumor, or the tumors, may not be con- 
fined to one side of the chest. It is to be borne in 
mind that pleurisy with effusion may exist as a 
complication, and this may serve to obscure the 
diagnosis. 

The physical diagnosis involves difterentiation 
from pericarditis with efi'usion and aneurisms. 
These affections are to be excluded by the absence 
of their diagnostic signs. 

Acute Miliary Tuberculosis. 

The physical condition in this affection is the 
presence of a large number of the small bodies 
known as tubercles or miliary granulations, dissemi- 
nated throughout both lungs. Bronchitis is' an 
associated affection. 

If the tubercles be about equally distributed in 
the two lungs, there is no abnormal disparity of the 
resonance on percussion between the two sides of 
the chest. A comparison, also, of the two sides may 
afford no disparity as regards the respiratory mur- 
mur, vocal resonance, and fremitus. Moist rales, 
due to the associated bronchitis, may be present in 



PHTHISIS. 193 

different situations. A physical diagnosis, under 
these circumstances, cannot be made with positive- 
ness. Physical exploration, however, is important 
in order to exclude other affections ; and the negative 
result, taken in connection with the symptoms — 
hyperpyrexia, rapid pulse, accelerated breathing, 
etc. — renders the diagnosis extremely probable. 
The differential diagnosis involves discrimination 
from capillary bronchitis, and an essential fever with 
a bronchial complication. The affection has been 
repeatedly mistaken for typhoid fever. 

The tubercles may be more abundantly distributed 
in one lung. A disparity in the resonance on per- 
cussion may then be apparent, and, perhaps, an 
abnormal increase of vocal resonance and fremitus. 
These signs, taken in connection with the symptoms, 
establish the physical diagnosis. 

Phthisis. 

With reference to physical diagnosis, cases of 
phthisis may be conveniently distributed into three 
groups, as follows : 1st. Cases in which the pul- 
monary affection is small, or cases of incipient 
phthisis; 2d. Cases in which the affection is mod- 
erate or considerable; and, 3d. Cases in which the 
affection has progressed to the formation of cavities, 
or cases of advanced phthisis. 

In cases of incipient phthisis, the essential physical 
condition is the presence of small solidified masses, 
or nodules, the intervening vesicular structure not 
being affected. These nodules vary from the size 
of a pea to a filbert. In the vast majority of cases 

17 



194 PHYSICAL DIAGNOSIS. 

they are situated at or near the apex of either the 
right or the left lung. Generally, circumscribed 
capillary bronchitis coexists in proximity to the 
nodules. An intercurrent circumscribed pneumonia 
sometimes occurs, giving rise to transient solidifica- 
tion within a limited area. Dry circumscribed 
pleurisy situated over the affected portion of lung, 
generally occurs from time to time. 

In the cases of a moderate or a considerable pul- 
monary affection, the difference, as compared with 
the preceding group of cases, consists in the presence 
of nodules of larger size, or solidification from the 
phthisical deposit extending over a space, or spaces, 
sufficient in size to give rise to well-marked physical 
signs. The solidification in these cases may be ex- 
tended by the development of circumscribed inter- 
stitial pneumonia. The circumscribed bronchitis is 
greater, as a rule, in degree and extent ; attacks of 
dry pleurisy may continue to occur, and the pleural 
surface becomes adherent. In these cases, generally, 
the affection, existing primarily in one lung, now 
exists in both lungs. The volume of the lung first 
affected, at the summit, is more or less diminished. 
Enlargement of the bronchial glands is usual, and 
these may be so situated as to press upon and dim- 
inish the calibre of one of the primary bronchi. In 
some cases, portions of lung in the neighborhood of 
solidified masses or nodules are emphysematous 
(vicarious emphysema). 

Cases of advanced phthisis are characterized by 
the presence of a cavity, or, commonly, of cavities, 
varying in number, size, rigidity or flaccidity of the 
walls, freedom of communication with bronchial 



PHTHISIS. 195 

tubes, and the nearness of their situation to the super- 
ficies of the lung. In cases of progressive phthisis, in 
addition to cavities, there is more or less solidification 
from phthisical exudation and interstitial pneumonia. 
The volume of the lung at the summit is often nota- 
bly diminished. The pleural surfaces are firmly 
adherent. If, however, the disease have been retro- 
gressive or non-progressive, there may be little or no 
solidification of lung, the cavity or cavities forming 
the only lesion. In cases of advanced phthisis, with 
very rare exceptions, both lungs are afiiectecl, and 
cavities often exist on both sides. 

The physical diagnosis in cases of incipient phthisis 
embraces what may be called direct and accessory 
signs. The accessory signs are those which repre- 
sent incidental aftections, namely, circumscribed 
bronchitis, pleurisy, and pneumonia. The direct 
signs are those representing the essential condition, 
namely, the solidified masses or nodules. 

An important direct sign is dulness on percussion. 
Slight dulness on percussion at the summit of the 
chest, in front or behind, is a highly important sign, 
taken in connection with symptoms, of incipient 
phthisis. In determining that a relative dulness is 
abnormal, the student must bear in mind, in the 
first place, the normal disparity between the two 
sides. The right side at the summit is relatively 
somewhat dull on percussion in healthy persons. 
Due allowance is to be made for this normal dis- 
parity. In the second place, it is to be borne in 
mind that any deformity affecting the symmetry of 
the chest will aftect the relative resonance on the 
two sides; and that a deviation from symmetry at- 



196 PHYSICAL DIAGNOSIS. 

tributable to the position of the patient will occa- 
sion a disparity on percussion. In the third place, 
the rules for the practice of percussion must be kept 
in mind, in order to avoid producing apparently an 
abnormal disparity by the non-observance of these 
rules {vide p. 60). JSTorraal resonance on percussion 
on the two sides is a strong point for the exclusion 
of incipient phthisis. 

The direct respiratory signs in incipient phthisis 
are the broncho-vesicular respiration and weakened 
vesicular murmur. To these is to be added a local- 
ized interrupted or wavy inspiratory murmur as an 
occasional sign. Of course, familiarity with the 
characters of the broncho-vesicular respiration is 
indispensable — the combination of the vesicular and 
the tubular quality in the inspiratory sound, with 
the pitch raised in proportion to the amount of 
tubularity, and the expiratory sound more or less 
prolonged, high, and tubular. ISTot infrequently the 
only appreciable morbid moditication is diminished 
intensity of the murmur. When this sign is present, 
it is probable that the lack of intensity is the reason 
for the absence of the characters of the broncho- 
vesicular modifications, that is, the latter sign would 
have been present were the respiratory sounds more 
intense. 

The direct vocal signs in incipient phthisis are, in- 
creased vocal resonance, increased bronchial whisper, 
and increased fremitus. The other direct signs may 
be present without an appreciable morbid increase 
of the vocal resonance or fremitus. The increased 
whisper may also be wanting, but more rarely than 
the two other vocal signs. 



PHTHISIS. 197 

111 deciding on the presence or absence of each 
and all of these direct signs, it is essential to know 
and to judge correctly of the disparity between the 
two sides of the chest at the summit in health. 
JSTormally the resonance on percussion at the 
summit on the right side is slightly dull as com- 
pared with the left side ; the inspiratory sound on 
this side has some tubularity in quality, and is 
somewhat raised in pitch; the expiratory sound 
may be more or less prolonged, high, and tubular; 
the vocal resonance on the right side is always 
greater, the same being true of fremitus ; the bron- 
chial whisper is louder on the right side, and the 
intensity of the respiratory murmur is a little less 
on this side. Whenever it is a question as to a 
small phthisical affection at or near the apex of the 
right lung, it is a matter of experience and judgment 
to decide if the disparity in respect of these points 
be greater than normal, and it is not always easy to 
come at once to a decision. From the want of a 
proper appreciation of the several points of disparity 
in health, it is not uncommon for an erroneous diag- 
nosis of phthisis to be based thereon. Appreciating 
the normal points of disparity, it is obviously easier 
to determine that the several direct signs of incipient 
phthisis are present at the left than at the right 
summit; relative dulness on percussion, broncho- 
vesicular or weakened respiration, increased vocal 
resonance, whisper, and fremitus, at the left summit 
are, of course, always abnormal. 

In connection with the foregoing direct signs may 
be mentioned another sign which is often available, 
namely, an abnormal transmission of the heart- 
17* 



198 PHYSICAL DIAGNOSIS. 

sounds. This sign is available only in the central 
portion of the infra-clavicular region. A slight de- 
gree of solidification of the summit of one lung 
renders the heart-sounds more audible in the situa- 
tion just named. It is of assistance in determining 
this sign to be familiar with the following points of 
disparity which exist in health : on the right side 
the second sound of the heart is somewhat more 
audible than on the left side, and on the left side 
the first sound is a little louder than on the right 
side. Hence, if the first sound be better transmitted 
on the right than on the left side, it is abnormal; 
and if the second sound be louder on the left side, 
it is abnormal. This sign is always to be taken in 
connection with other direct signs ; it gives greater 
diagnostic strength to the latter, but it is by no 
means, in itself, sufiicient for the diagnosis. 

Corroborative evidence of incipient phthisis may 
be obtained by the presence of accessory signs. 
These are: First, fine bubbling or the so-called sub- 
crepitant rale at the summit on one side. This 
sign denotes a circumscribed capillary bronchitis, 
and this, at the summit on one side, is usually asso- 
ciated with phthisis. Second, a crepitant rale at the 
summit on one side denotes a circumscribed pneu- 
monia which is usually secondary to phthisis. Third, 
a pleuritic friction-sound limited to the summit on 
one side is evidence of a dry circumscribed pleurisy 
which occurs often in the early stage of phthisis. 
Fourth, indeterminate rales, crumpling and crack- 
ling, are significant of phthisis if limited to the 
summit on one side. These rales, it is to be recol- 
lected, are sometimes found in healthy persons on 



PHTHISIS. 199 

forced breathing, especially if the binaural stetho- 
scope be employed. If they be normal they are 
found on both sides. The accessory signs are not 
sufficient for a positive diagnosis if they exist alone; 
but they are to be considered as corroborating the 
evidence derived from the direct signs, together 
with the symptoms and history. It is of service 
often in bringing out the rales to cause the patient 
to cough. 

As regards diflerential diagnosis, the affections 
with which incipient phthisis is likely to be con- 
founded are chronic bronchitis and moderate em- 
physema. With respect to the first of these afflic- 
tions, namely, bronchitis, the difierentiation must 
depend on the presence or the absence of positive 
signs of phthisis ; in other words, phthisis is either 
diagnosticated or excluded. The physical signs in 
cases of moderate emphysema sometimes lead to 
the error of supposing this affection to be phthisis. 
Owing to the relatively greater intensity of the 
resonance on percussion at the left summit, dulness 
is thought to exist at the right summit, and a pro- 
longed expiration, with the normally greater vocal 
resonance at the right summit, are regarded as signs 
ot phthisis. This error may be avoided by a careful 
study of the signs of emphysema and the normal 
disparity in respiration, vocal resonance, and fre- 
mitus, existing between the two sides of the chest. 

The physical diagnosis of a phthisical affection 
which is considerable or moderate in amount, is, in 
most cases, an easy problem. Inspection often fur- 
nishes marked signs. The upper anterior portion 



200 PHYSICAL DIAGNOSIS. 

of the chest on one side is depressed or flattened, 
and the superior costal movements of respiration 
are diminished, the chest elsewhere being sym- 
metrical in both size and motions. There is more 
or less marked dulness on percussion at the upper 
part of the chest on the affected side. Sometimes 
the diminished resonance is tympanitic in quality 
(tympanitic dulness) without the existence of cavi- 
ties, the resonance being transmitted from the pri- 
mary and secondary bronchial tubes. The respiration 
is either bronchial or broncho-vesicular approximat- 
ing more or less to the bronchial. Occasionally, how- 
ever, the respiratory sounds are too feeble for their 
characters to be appreciated. There is either bron- 
chophony, or the vocal resonance is notably increased 
without the bronchophonic characters. The whisper 
is either distinctly bronchophonic or it is notably in- 
creased in intensity, high in pitch, and tubular in 
quality. Vocal fremitus is often increased. Moist 
bronchial rales, coarse or fine, are generally present. 
"With these diagnostic signs on one side, the signs of 
a smaller amount of disease are generally present on 
the other side. 

In some cases of a moderate phthisical affection, 
the judgment may be confused by the resonance on 
percussion being increased or vesiculo-tympanitic 
on the affected side. This sign denotes the coex- 
istence of emphysematous lobules (vicarious emphy- 
sema) developed in the progress of phthisis. The 
diagnosis of the latter affection is then to be based 
on the signs obtained by auscultation. 

In advanced phthisis the physical diagnosis of the 
disease is easy. The signs distinctive of this stage 



FIBROID PHTHISIS, ETC. 201 

of the disease are those which denote pulmonary 
cavities, namely, tympanitic resonance on percus- 
sion within a circumscribed space ; cracked-metal 
or amphoric resonance; cavernous respiration ; cav- 
ernous whisper and sometimes pectoriloquy ; am- 
phoric respiration and voice, and gurgling {vide 
Chapter Y. for description of these signs). 

The cavernous signs are generally associated with 
the signs of solidification. In some cases, however, 
in which the disease has been non-progressive and 
retrogressive, the cavernous signs are present with- 
out the signs which denote solidification of lung. 

Fibroid Phthisis — Interstitial Pneumonia, or Cirrhosis 
of Lung-. 

In this affection the physical conditions are, solidi- 
fication from hyperplasia of the interstitial pulmonary 
tissue, dilatation of bronchial tubes (bronchiectasis), 
and diminished volume of the lung affected. The 
afifection, as a rule, is either limited to or especially 
marked on one side. The whole of a lung, or only 
a portion of it, may be affected. Bronchitis always 
coexists. 

There is notable dulness on percussion, the di- 
minished resonance being sometimes tympanitic. 
The degree of resonance may vary at different ex- 
aminations, owing to diffJerences in the amount of 
morbid products within the bronchial tubes. The 
respiration is bronchial, or broncho-vesicular. At 
times, from obstruction of bronchial tubes, it may 
be suppressed. Bronchophony and increased vocal 
resonance are the vocal signs, together with the 
corresponding whispering signs. The side of the 



202 PHYSICAL DIAGNOSIS. 

chest which is chiefly or exclusively afl:ectecl be- 
comes contracted either entirely or in part, resem- 
bling in this respect the appearances after chronic 
pleurisy. 

"With these signs the affection is to be differen- 
tiated from the ordinary form of phthisis, by refer- 
ence to points pertaining to the symptoms and 
histor3^ 

Diaphragmatic Hernia. 

The presence of more or less of the abdominal 
viscera within the thoracic cavity in consequence of 
a congenital deficiency of a portion of the diaphragm, 
or perforation from accidents, or enlargement of the 
natural openings, gives rise to certain anomalous 
signs, namely, a tympanitic resonance, variable at 
different times owing to differences as regards the 
quantity of gas within the viscera; absence of the 
respiratory murmur from the base of the chest 
upward, the height proportional to the space oc- 
cupied by the abdominal organs, and the intestinal 
sounds emanating from within the chest, not con- 
ducted from below. 

This extremely rare affection can only be con- 
founded with pneumothorax. The latter affection 
is to be excluded by the absence of its diagnostic 
signs, irrespective of the tympanitic resonance on 
percussion. 



CHAPTER VII. 

THE PHYSICAL CONDITIONS OF THE HEAKT IN 
HEALTH AND DISEASE. THE HEAET-SOUNDS AND 
CAKDIAC MUPvMUKS. 

Physical conditions of the heart in health : Boundaries of the preecordia 
— Normal situation of the apex-beat — Boundaries of the deep and of the 
superficial cardiac space — Relations of the aorta and the pulmonary 
artery to the walls of the chest — The heart-sounds — Characters dis- 
tinguishing the first and the second sound — Mechanism of the produc- 
tion of the heart-sounds — Auscultation of the pulmonic and the aortic 
second sound separately — Movements of the auricles and ventricles in 
relation to each other — Physical conditions of the heart in disease: 
Enlargement of the heart — Hypertrophy and dilatation — Abnormal 
impulses of the heart, and modifications of the apex-beat — Valvular 
lesions — Roughness of the pericardial surfaces — Liquid within the 
pericardial sac — Abnormal modifications of the heart-sounds — Re- 
duplication of heart-sounds — Cardiac murmurs — -Normal and abnormal 
blood-currents within the heart, and their relations with the heart- 
sounds — -Mitral direct murmur — Mitral regurgitant murmur — Mitral 
systolic non-regurgitant, or intra-ventricular murmur — Aortic direct 
murmur — Aortic regurgitant murmur, and in Aortic diastolic non- 
regurgitant murmur — Coexisting endocardial murmurs — Tricuspid 
direct murmur — Tricuspid regurgitant murmur — Pulmonic direct 
murmur — Pulmonic regurgitant murmur — Facts of practical impor- 
tance in relation to endocardial murmurs — Pericardial or friction 
murmur. 

Before entering upon the study of the physical 
diagnosis of the diseases of the heart, the student 
must be familiar with its anatomy and physiology. 
For a description of the structure and functions of 
this organ, he is referred to anatomical and physio- 
logical treatises. The plan of this work embraces 
the anatomical relations of the heart and the space 



204 THE HEART. 

which it occupies within the chest, as physical con- 
ditions of health determinable by normal signs, 
together with the heart-sounds. Having briefly 
stated these conditions of health, the morbid physical 
conditions which may be ascertained by percussion, 
auscultation, and other methods of physical explora- 
tion, will be considered. The latter heading will 
include an account of the cardiac murmurs. 

The Physical Conditions of the Heart in Health. 

The Prcecordia — The Superficial and the Deep Cardiac 
Space. — The area on the surface of the chest corre- 
sponding to the space which the heart occupies 
within the chest, is the prsecordial region or the 
prsecordia. The upper, lower, and two lateral 
boundaries of this region must be memorized. The 
upper boundary is the third rib, the lower is a hori- 
zontal line passing through the fifth intercostal 
space ; the left lateral boundary is at, or a little 
within, a vertical line passing through the nipple, 
the tinea mammillaris, and the right lateral boundary 
is represented by a vertical line situated about a 
finger's breadth to the right of the right margin of 
the sternum. As the volume of the heart varies, 
within certain limits, in difterent healthy persons, 
the boundaries of the prtecordia are, of course, not 
always exactly the same. The foregoing statements 
are sufiiciently accurate for practical purposes. 

The horizontal line representing the lower boun- 
dary of the prsecordia intersects the point where the 
apex-beat of the heart is felt. The normal situation 
of the apex-beat must be recollected. In most 



CONDITIONS OF HEART IN HEALTH. 205 

healthy persons the apex-beat is felt in the fifth 
intercostal space, a little within the linea mammil- 
laris. This is assuming the persons to be sitting or 
standing ; in recumbency on the back the beat 
sometimes rises to the fourth intercostal space, and 
it is sometimes found in the fourth space in the sit- 



FlG. 11. 




ting or standing position of the body. The distance 
from the linea mammillaris varies in difierent healthy 
persons ; it is sufficiently accurate to say it is a little 
within that line. (Fig. 11.) The force of the apex- 
beat varies much in different healthy persons, owing 
to other causes than the power of the heart's action, 



206 THE HEART. 

such as the amount of muscular substance and fat in 
that situation, the width of the intercostal space, the 
convexity of the chest, the relation to the left lung, 
etc. Allowance is to be made for these variations 
in determining the abnormal modifications of the 
force of the beat, which belong among the physical 
signs of disease. 

Within a portion of the pra^cordia the heart is 
uncovered of lung, and in the remaining portion 
lung intervenes between the heart and the walls of 
the chest. The former of these portions is called 
the superficial, and the latter is called the deep 
cardiac space. The deep cardiac space on the right 
side extends to the median line. On the left side 
the lung recedes at a point on the median line on a 
level with the cartilage of the fourth rib, and the 
anterior border of the upper lobe makes an outward 
cur\'e, returning inward at or near the apex of the 
heart. This leaves the heart uncovered within an 
area which, for practical purposes, may be repre- 
sented by a right-angled triangle, the hypothenuse 
extending from the median line on a level with the 
costal cartilage of the fourth rib to the apex of the 
heart; the right angle formed by the median line 
and the horizontal line which forms the lower boun- 
dary of the preecordia. (Figs. 11 and 12.) 

The limits of the superficial cardiac space may be 
easily defined by percussion. It is only necessary to 
ascertain the curved line formed by the receding 
anterior border of the upper lobe of the left lung. 
A distinct, although not great, dulness on percussion 
marks this border of the lung. The border of the 
lung is as distinctly marked by the abrupt diminu- 



CONDITIONS OF HEART IN HEALTH 207 

tion of the vocal resonance, if auscultation be made 
with the stethoscope. The outer boundaries of the 
deep cardiac space may also be determined by per- 
cussion ; distinct, although slight dulness marks the 
limits of the preecordia. Defining thus the boun- 
daries of the prfecordia and of the superficial cardiac 

Fia. 12. 




V- 



W 




space in healthy persons, makes a good practical 
exercise in percussion. 

Relations of the Aorta and Pulmonary Artery to the 
Walls of the Chest. — The base of the heart, especially 
in connection with auscultatory signs, is generally 



208 THE HEART. 

considered to be at the second intercostal space near 
the sternum, this situation being, in reality, just 
above the base. In this situation sounds produced 
at the aortic and the pulmonic orifice are best studied, 
either in health or disease. With reference to these 
sounds, the anatomical relations of the aorta and the 
pulmonary artery to the right and the left second 
intercostal space are of importance. If the stetho- 
scope be applied in the second intercostal space on 
the right side, close to the sternum, it is very near 
the aorta, and sounds produced at the aortic orifice 
are best heard in this situation. If the stethoscope 
be applied in the second intercostal space on the left 
side, it is very near the pulmonary arterj^, and the 
sounds produced at the pulmonic orifice are best 
heard in this situation. Reference will be made to 
these two situations in giving an account of the 
heart-sounds in health and disease, and of adventi- 
tious sounds or murmurs. (Fig. 11.) 

The Heart-sounds. — It is customary to consider the 
heart-sounds as two in number, and to distinguish 
them as the first, or systolic, and the second, or 
diastolic, sound. The characters which distinguish 
the heart-sounds in health are to be studied prepara- 
tory to the study of the abnormal modifications 
which are important physical signs of disease. It is 
essential to be able always to make the distinction 
practically between the so-called first, or systolic, 
and the second, or diastolic, sound in order to con- 
nect with them separately cardiac murmurs. The 
conventional use of the term heart-sounds, as dis- 
tinguished from cardiac murmurs, must be borne in 
mind. The cardiac murmurs are adventitious 



CONDITIONS OF HEART IN HEALTH. 209 

sounds; they are never merely abnormal modifica- 
tions of the heart-sounds, but they are new sounds 
added to or replacing these. 

Considering the heart-sounds as two in number, 
namely, the first, or systolic, and the second, or 
diastolic, these follow in a certain rhythmical order, 
and, in health, this sutfices for the recognition of 
each. It answers all practical purposes to say that 
the sounds follow each other after an interval which 
is just appreciable, this interval being the short 
pause of the heart. After the occurrence of both, 
an interval is readily appreciable, called the long 
pause of the heart. It is not necessary to carry in 
the memory the exact relative duration of each of 
the two sounds and each of the two intervals. The 
fractions of a unit, in fact, do not express the length 
of the sounds and intervals as correctly as less defi- 
nite expressions, inasmuch as the figures represent 
only the mean of variations within the limits of 
health. It is sufficiently exact to say that, with the 
ear or stethoscope applied over the situation of the 
apex-beat, the systolic sound is longer than the 
diastolic, louder, lower in pitch, and has a quality 
which may be called booming. Per contra, the dias- 
tolic sound is shorter, weaker, higher in pitch, and 
has a quality which may be called valvular or click- 
ing. Aside from the relative length, the other char- 
acters are more or less marked in different healthy 
persons. 

These distinctive characters of the systolic and 

diastolic heart-sounds are apparent when the ear or 

stethoscope is applied over the apex. At the base 

of the heart, that is, in the second intercostal space 

18* 



210 THE HEART. 

near the stenniiii, the eliaracters of the systolic sound 
are not the same as over the apex. The diastolic 
sound in this situation is louder than the systolic. 
The latter is said to be accentuated at the base, the 
systolic sound being accentuated at the apex. More- 
over the systolic sound at the base may not be longer 
than the diastolic; it loses more or less of its boom- 
ing quality, the pitch remaining lower than that of 
the diastolic sound. Removing the ear or the steth- 
oscope a certain distance from the apex in any direc- 
tion, occasions similar changes in the characters of 
the systolic sound. The interposition of several 
thicknesses of a iKqfkin has the same effect. 

From the differential characters over the apex, and 
the rhythm alone in other situations, there is no diffi- 
culty in distinguishing the systolic from the diastolic 
sound in health. In cases of disease, however, owing 
to disturbance of the rhythm, modifications of the 
characters of the systolic sound, and the absence 
sometimes of one of the sounds, other means of 
recognition must be resorted to. If the apex-beat 
can be felt, this offers a ready way for recognizing 
the systolic sound — the sound which is synchronous 
witli the apex-beat is, of course, the systolic sound. 
This mode is not always available, inasmuch as the 
apex-beat cannot always be felt. Another mode is 
always available, namely, feeling the carotid pulse. 
The carotid pulse is synchronous with the systolic 
sound, whereas there is a slight interval between this 
sound and the radial pulse. 

The student is aided in comprehending certain 
physical signs by taking into view the mechanism of 
the production of the heart-sounds. The diastolic 



CONDITIONS OF HEART IN HEALTH. 211 

sound is produced by the sudden forcible closure of 
the aortic and the pulmonic valves. This closure is 
caused by a retrograde movement of the columns of 
blood in the aorta and pulmonary artery, directly 
the ventricular sj'stole is ended. The retrograde 
movement is due to the recoil of the coats of the 
arteries which have been dilated by the column of 
blood moving onward during the ventricular systole. 
This recoil causes regurgitation into the ventricle 
when either the aortic or the pulmonic valve is ren- 
dered incompetent by lesions. The mechanism of 
the systolic sound is less simple. This sound is in 
part due to the forcible tension of the auriculo- 
ventricular valves, caused by the systole of the ven- 
tricles. In this way is produced a valvular element 
of the systolic sound. That the impulsion of the 
heart against the walls of the chest furnishes another 
element, seems demonstrable. To this element of 
impulsion the systolic sound is indebted for its greater 
Intensity, as compared with the diastolic sound, its 
length, and its booming quality. This is shown by 
the fact, already stated, that when auscultation is 
made at a certain distance from the apex, these 
characters are eliminated, and by the fact that dis- 
eases which diminish or arrest the impulsion move- 
ments of the heart produce the same modifications. 
The valvular element of the systolic sound is weaker 
than the diastolic sound, a fact which at first occa- 
sions surprise when the difference in size between 
the aortic and pulmonic and the auriculo-ventricular 
valves is considered. The explanation of this appa- 
rent incongruity is as follows : the aortic and pul- 
monic segments at the end of the ventricular systole 



212 THE HEART. 

are in contact with the arterial walls, and are ex- 
panded when the recoil of the latter follows. On 
the other hand, when the ventricular systole takes 
place in health, the auriculo-ventricular valves are 
not in contact w4th the walls of the ventricles, but 
they are floated out, and the orifices are nearly or 
quite closed ; the movement of the blood, therefore, 
in the systole only renders these valves tense. The 
diastolic sound, in other words, is due to the expan- 
sion of the sigmoid valves of the aorta and pulmonary 
artery, whereas, the valvular element of the systolic 
sound is due to merely tension of the auriculo- 
ventricular valves. The foregoing points relating to 
the heart-sounds were contained in my prize essay 
" On the Clinical Study of the Heart-sounds in 
Health and Disease," published in the Iransactions 
of the American Medical Association, in 1852.' 

With reference to important bearings on ausculta- 
tion in disease, the diastolic or second sound is to be 
studied as produced at the aortic and the pulmonic 
orifice separately. Recalling the anatomical rela- 
tions of the aorta and the pulmonary artery to the 
walls of the chest, if the stethoscope be applied in 
the second intercostal space on the right side close 
to the sternum, the characters of the diastolic sound 
are derived chiefly from the aortic valve, and if the 
stethoscope be applied in the second intercostal 
space on the left side close to the sternum, the char- 
acters of the diastolic sound are derived chiefly from 
the pulmonic valve. The correctness of this state- 
ment is proved by differences in the characters of 

1 Vide, also, " Treatise on Diseases of the Henri," first edition, 
1860; second edition, 1870. 



CONDITIONS OF HEART IN HEALTH. 213 

the sound on two sides in health, and by the modi- 
fications in cases of disease. These morbid modifi- 
cations will enter into the physical diagnosis of car- 
diac afiJections. In health the aortic diastolic sound 
is somewhat louder, higher in pitch, and the valvular 
quality more marked than the pulmonic diastolic 
sound. The student should verify these points of 
difference by the study of the diastolic sound in the 
two situations just named. In order for the com- 
parison to be a fair one in health, and available in 
the diagnosis of disease, the normal anatomical re- 
lations to the walls of the chest, of the aorta, and 
pulmonary artery must be preserved. These rela- 
tions are affected by changes in the symmetry of the 
chest, and sometimes by enlargement of the heart. 
The lungs must also be free from disease ; otherwise, 
the transmission of the sounds will be abnormal. 

In the account of the mechanism of the production 
of the heart-sounds {vide page 211), it was stated that 
the first or systolic sound consists of a valvular ele- 
ment and an element of impulsion. This valvular 
element is a two-fold sound, that is, it is a combina- 
tion of a sound produced by the mitral and a sound 
produced by the tricuspid valve. These two valvular 
synchronous sounds may be studied separately in 
health, and their abnormal modifications constitute 
important diagnostic signs in cases of disease. This 
fact, which was pointed out in my prize essay " On 
the Clinical Study of the Heart-sounds," in 1852, 
has not received, as yet, from medical writers the 
attention which its importance deserves. 

The two valvular sounds may be designated the 
mitral and the tricuspid systolic sound. Adding to 



214 THE HEART. 

these two sounds, the sound of impulsion produced 
hy the movements of the apex, with the ventricular 
systole, are three distinct sounds. The diastolic or 
second sound of the heart, as has been seen, is re- 
solvable into two distinct sounds. Hence, the num- 
ber of distinct heart-sounds is, in reality, live, two of 
which are diastolic and three systolic, namely, the 
mitral valvular, the tricuspid valvular, the sound of 
impulsion, the aortic and the pulmonic. Each of 
these five sounds may be studied separately in health 
and disease. The abnormal modifications of each 
furnish important information in diagnosis. 

In health, the sound of impulsion is heard over 
the situation of the apex-beat of the heart. The 
mitral valvular sound is studied by listening with 
the stethoscope applied to the left of the apex at a 
distance sufficient to eliminate the sound of im- 
pulsion. 

The tricuspid valvular sound is heard at a little 
distance to the right of the inferior border of the 
heart. 

In the pages which follow I shall sometimes refer 
to the systolic and the diastolic sound in the singular 
number, it being understood that the systolic sound 
embraces three, and the diastolic two, components; 
and at other times I shall refer to the sounds sepa- 
rately which are combined in the two sounds.' 

The order of the succession of the movements of 
the auricles and of the ventricles is to be kept in 
mind with reference to the comprehension of certain 

^ Vide paper on the clinical study of the heart-sounds, by the 
Author, in the Journal of the American Med. Association, 1884. 



CONDITIONS OF HEART IN DISEASE. 215 

physical signs of disease. Points of especial impor- 
tance are the contraction of the auricles in the latter 
part of the long pause of the heart, preceding the 
ventricular systole, and the twisting of the heart 
from left to right in the systole, this movement being 
reversed in the diastole. In these systolic and dias- 
tolic twisting movements, the pericardial surfaces 
move upon each, but in health noiselesslj^ owing to 
their smoothness and moisture. The movements 
occasion an auscultatory sign, namely, a friction 
murmur, when the surfaces are roughened by the 
presence of lymph. Other points are the size of the 
pericardial sac, that is, its capability of holding when 
tilled, but not dilated, from fifteen to twenty ounces 
of liquid, and its attachment, not to the base of the 
heart, but to the vessels above the 



Physical Conditions of the Heart in Disease. 

The physical conditions of the heart in disease, 
which are determinable by physical exploration, are, 
1st, enlargement of the heart; 2d, abnormal im- 
pulses and modifications of the apex-beat; 3d, 
valvular lesions; 4th, roughness of the pericardial 
surfaces; and, 5th, liquid within the pericardial sac. 
Having considered these conditions, an account of 
abnormal moditications of the heart-sounds and 
cardiac murmurs will conclude this chapter. 

Enlargement of the Heart. — Enlargement of the 
heart may be slight, moderate, great, or very great, 
these terms expressing diflerent degrees of enlarge- 
ment with sufficient precision for clinical purposes. 
In cases of very great enlargement, the space within 



216 THE HEART. 

the chest which the heart occupies may be from four 
to live times larger than in health. The situation 
of the base of the heart remains but little, or not at 
all, changed in cases of enlargement; the increased 
space which the heart occupies is therefore down- 
ward. The increased space extends much more to 
the left than to the right; the left border of the 
heart, in proportion to the enlargement, is carried 
beyond the mammary line on the left side, whereas, 
the right border is carried comparatively but little 
beyond the normal right lateral boundary of the 
prpecordia even when the enlargement is very great. 
The superficial cardiac space is enlarged in propor- 
tion to the enlargement of the heart; the organ 
pushes to the left the receding anterior border of the 
upper lobe of the left lung, and is proportionately 
in contact, uncovered of lung, with the walls of the 
chest. The apex of the heart is lowered in propor- 
tion to the enlargement, and it is carried more or 
less to the left of its normal situation. It may be 
lowered to the sixth, seventh, eighth, or ninth inter- 
costal space. The enlargement of the heart is rarely 
equal in all its parts. The ventricular enlargement 
may be entirely or chiefly of either the right or the 
left ventricle. Enlargement of the right ventricle 
tends to carrj' the right side of the heart more to the 
right than when the left ventricle is enlarged. The 
situation of the apex is also affected by the parts of 
the heart in which the enlargement predominates. 
The apex is carried further to the left of its normal 
situation, other things being equal, when the en- 
largement predominates on the right side of the 
heart; and it is lowered without being carried far 



CONDITIONS OF HEART IN DISEASE. 217 

to the left when the enkxrgement of the left ventricle 
predominates. The apex of the organ in cases of 
considerable or of great enlargement becomes 
changed in form ; it is rounded or blunted. This 
change is most marked when enlargement of the 
right ventricle predominates. All these points are 
of importance with reference to the comprehension 
of the physical signs of enlargement of the heart. 

Enlargement of the heart may be entirely due 
either to hypertrophy or to dilatation (simple hyper- 
trophy and simple dilatation). If, however, the 
enlargement be sutficient to occasion notable dis- 
turbance of the circulation, both these forms of 
enlargement are combined, but, as a rule, one or 
the other form predominating, so that, of the cases 
of diseases of the heart which come under medical 
treatment, the majority are cases of either enlarge- 
ment with predominant hypertrophy or enlargement 
with predominant dilatation. 

These widely difierent physical conditions are 
concerned especially in the abnormal impulses and 
moditications of the apex-beat, as well as, also, the 
heart-sounds. 

Abnormal Impulses of the Heart, and 3Iodifications of 
the Apex-heat. — The abnormal situation of the apex 
of the heart when enlarged has been stated. Gen- 
erally the situation is determinable by the apex-beat. 
It has been seen that in health the beat is sometimes 
not appreciable by the touch, owing to the thickness 
of the soft parts, and the conformation of the thorax, 
and, for these reasons, the force of the beat varies 
much in different healthy persons. Exclusive of 
normal variations, the beat is generally strong and 

19 



218 THE HEART, 

prolonged in proportion as the heart is enlarged by 
hypertrophy. There are exceptions to this state- 
ment, which are to be explained by the altered form 
of the apex; when it loses its pointed form it does 
not so readily come into contact with the walls of 
the chest in an intercostal space, and, hence, the beat 
may be weak although the ventricular systole be 
abnormally strong. On the other hand, the apex- 
beat is weakened by dilatation, and it may be want- 
ing as a result of diminished strength of the systole 
of the ventricles. The apex-beat is also abnormally 
weak in fatty degeneration and softening of the 
heart, as well as in functional debility of the organ 
incident to other diseases than those of the heart. 

If there be considerable or great enlargement, the 
heart being in contact with the walls of the chest 
over a larger area than in health, impulses other 
than the apex-beat are generally apparent to the eye 
and touch. Kot infrequently impulses are appre- 
ciable in each intercostal space between the situation 
of the apex and the base of the heart. These ab- 
normal impulses are felt to be strong in proportion 
as the enlargement is due to hypertrophy, and weak 
in proportion as dilatation predominates. Enlarge- 
ment seated in the right ventricle causes an impulse 
in the epigastrium which is strong or weak in pro- 
portion as hypertrophy or dilatation predominates. 
Cardiac impulses are felt and seen in abnormal situ- 
ations when the heart is removed from its normal 
situation by the pressure of an aneurism, or other 
tumor, by pleuritic effusion, hydroperitoneum, etc. 
The error of mistaking for a cardiac impulse the 
pulsation of an aneurismal tumor is to be avoided. 



CONDITIONS OF HEART IN DISEASE. 219 

Another error is to be avoided, namely, mistaking 
abnormal impulses due to the heart being uncovered 
of lung, from shrinking of the latter in certain pul- 
monary affections, for impulses denoting enlarge- 
ment of the heart. In cases of enlargement by 
hypertrophy, a heaving movement of the whole 
preecordia is sometimes felt when the hand is applied 
to the chest. A violent shock is sometimes felt by 
the hand applied to the prsecordia, but without a 
sense of increased muscular power, in cases of purely 
functional disorders of the heart. 

Valvular Lesions. — The lesions affecting the valves 
of the heart are of a varied character, for an account 
of which the student is referred to treatises on car- 
diac diseases, or on pathological anatomy. It suffices 
here to consider that, with reference to physical signs 
and pathological effects, they may be distributed into 
three groups, as follows : Ist, lesions which diminish 
more or less the size of the orifices, or obstructive 
lesions ; 2d, lesions which render the valves more or 
less incompetent and permit regurgitation, or re- 
gurgitative lesions; and, 3d, lesions which roughen 
the surfaces over which the blood moves without 
occasioning either obstruction or regurgitation. The 
latter may be distinguished as innocuous lesions, 
giving rise to no pathological effects although repre- 
sented by cardiac murmurs. 

It is to be borne in mind that in the great majority 
of cases valvular lesions are seated in the left side of 
the heart, that is, they are either mitral or aortic. 
Tricuspid and pulmonic lesions are comparatively 
rare, and they are generally congenital. N"ot infre- 
quently mitral and aortic lesions coexist, and there 



220 THE HEART. 

may be coexisting lesions at all the orifices of the 
heart. 

Valvular lesions are represented by cardiac mur- 
murs. By means of the murmurs the existence of 
lesions is known, their situation at the different 
orifices may be ascertained, and, generally, it is 
practicable to determine whether they occasion ob- 
struction or regurgitation, or both. These several 
points of inquiry will be considered presently under 
the heading Cardiac Murmurs, and in connection 
with the lesions of the different valves respectively 
in the next chapter. 

Roughness of the Pericardial Surfaces. — In place of 
the smoothness of the pericardial surfaces in health, 
which permits their movements upon each other 
noiselessly, the presence of the inflammatory product 
lymph, and, in some rare instances, morbid growths, 
occasion an adventitious sound or murmurs, which 
will be noticed in connection with other murmurs, 
and as entering into the physical diagnosis of peri- 
carditis. 

Liquid loithin the Pericardial Sac. — More or less 
liquid transudes into the pericardial sac in cases of 
general dropsy or anasarca, but rarely in very large 
quantity. Liquid effusion occurs in acute peri- 
carditis, and in this affection the sac may become 
filled with liquid. In some cases of chronic peri- 
carditis the sac is greatly dilated by liquid, the 
quantity amounting to four pounds, or even more. 

When the pericardial sac is filled with liquid, 
without being dilated, it forms a pyriform tumor 
within the chest, the base of which is at the sixth or 
seventh intercostal space ; the apex rises nearly to 



ABNORMAL MODIFICATIONS OF SOUNDS. 221 

the sternal notch ; the left lateral border is consider- 
ably beyond the nipple, and the right lateral border 
is more or less beyond the right margin of the prse- 
cordia. The anterior portion of the filled pericar- 
dium is mostly uncovered of lung and in contact 
with the walls of the chest. Within this area there 
is either notable dulness or flatness on percussion, 
together with absence of respiratory murmur and of 
vocal resonance. By means of these signs, the 
boundaries of the pyriform tumor may be readily 
delineated on the surface of the chest. The difl^er- 
ence in form and situation of the area of dulness or 
flatness on percussion in cases of large pericardial 
efi'usion, from the area in cases of enlargement of the 
heart {vide page 216), is to be noted and borne in 
mind with reference to the differential diagnosis. 

When the pericardial sac is partially filled with 
liquid, the same signs are present, but within an 
area of less extent, and the configuration of the 
pyriform tumor is wanting. 

In cases of chronic pericarditis with a large accu- 
mulation of liquid, the pericardial sac is dilated so 
that its lateral boundaries may extend nearly to the 
axillary and infra-axillary regions. Under these 
circumstances, flatness on percussion, absence of 
respiratory murmur and of vocal resonance, are 
present over the greater part of the anterior aspect 
of the chest. 

Abnormal Modifications of the Heart-sounds. 

In order to appreciate the abnormal modifications 
of the heart-sounds, their normal characters are to 
be kept in mind [vide page 209), and the student 
19* 



222 THE HEART. 

must be practically familiar with them. The modi- 
fications relate to the three components of the 
systolic sound, and to the two components of the 
diastolic sound, collectively and separately. 

The sound of impulsion, as heard over the apex, 
is intensified in hypertrophy of the heart. This 
sound is not only notably loud, but prolonged, and 
its booming quality is marked. It sometimes has a 
ringing tone, called tinnitus. The systolic valvular 
sounds, namely, the mitral and the tricuspid, are 
also more or less increased in intensity. The in- 
creased intensity of either the mitral or the tricuspid 
valvular sound, separately denotes that the hyper- 
trophy is seated especially in either the left or the 
right ventricle. 

In some cases of violent palpitation the systolic 
sounds are notably intensified, the sound of impul- 
sion being comparatively weak. I suppose the 
explanation to be as follows : the ventricles contract 
with a kind of spasmodic action upon a small quan- 
tity of blood ; and, under these circumstances, the 
auriculo-ventricular valves, not being floated out as 
they are when the ventricles are well filled, expand 
with force in the ventricular systole, instead of being 
merely made tense as in health. Hence, the valvular 
sounds are intensified, while the sound of impulsion 
may be feeble or wanting. The sound of impulsion 
over the apex is weakened or lost as an eftect of 
those affections of the heart which diminish the 
power of the ventricular systole. These affections 
are enlargement from dilatation, atrophy, fatty de- 
generation, myocarditis, obstruction of the coronary 
arteries, and softening. The systolic valvular sounds 



ABNORMAL MODIFICATIONS OF SOUNDS. 223 

are also more or less weakened, but in a less degree 
than the sound of impulsion. The loss of the sound 
of impulsion over the apex renders the so-called first 
or systolic sound of the heart short and valvular in 
qualit3\ 

Liquid effusion within the pericardium renders the 
sound of impulsion over the apex more or less weak. 
If the liquid efiusion be large, only the systolic val- 
vular sounds, namely, the mitral and tricuspid, are 
appreciable. Diminished power of the heart's action 
from other than cardiac diseases, involves weakness 
of all the heart-sounds, but more especially of the 
sound of impulsion. 

Abnormal modifications of the diastolic sound re- 
late to the aortic and pulmonic sounds considered 
separately. Bearing in mind the mode of interro- 
gating the aortic and the pulmonic orifice with 
reference to the valvular sound derived from each 
independently of the other [vide page 213), a com- 
parison of the two sounds in diseases of the heart 
afi:brds often useful information. Whenever, from 
mitral obstructive or regurgitant lesions, or both 
combined, the quantity of blood propelled by the 
left ventricle into the aorta is diminished, the recoil 
of the arterial coats, after the ventricular systole, is 
lessened ; consequently, the aortic segments expand 
with less force, and the aortic sound is weakened. 
Diminished intensity of the aortic sound thus repre- 
sents an abnormal diminution of the quantity of 
blood propelled into the systemic arteries by the 
systole of the left ventricle, and this diminished in- 
tensity of sound is, in a measure, a criterion of the 
amount of mitral obstruction or mitral regurgitation, 



224 THE HEART. 

or both combined. Ln some cases of great obstruc- 
tion or regurfi^itation, the aortic sound is completely 
suppressed. How is weakening of this sound to be 
determined and measured? By comparison with 
the pulmonic sound. ISTow, as will presently appear, 
the pulmonic sound is often intensified when the 
aortic sound is weakened. Hence, the former is not 
an accurate standard for this comparison ; but it 
suffices for an approximation to accuracy. In cases 
of hypertrophy of the left ventricle without obstruc- 
tive or regurgitant valvular lesions, the aortic sound 
is abnormally intensified. These cases occur chiefly 
in connection with fibroid or atrophic lesions of the 
kidneys. Intensification of the aortic sound may be 
due to increased tension of the systemic arteries 
without cardiac hypertrophy. 

A simpler cause of weakening or suppression of the 
aortic sound, is damage from lesions of the aortic 
valve. In proportion as the function of this valve is 
impaired by lesions, the intensity of the sound is 
diminished, and if the function of the valve be lost, 
the sound is wanting. In these cases, the pulmonic 
sound being but little or not at all afiected, it is an 
accurate standard for the comparison. 

The pulmonic sound is weakened in the rare in- 
stances of lesions aftecting the pulmonic valve. This 
sound is oftener intensified than weakened. It is 
notably intensified when the right ventricle is hyper- 
trophied, and especially when this hypertrophy is 
associated with dilatation of the left auricle resulting 
from mitral obstruction or regurgitation. These 
lesions weakening, as has just been seen, the aortic 
sound, the contrast between the aortic and the pul- 



ABNORMAL MODIFICATIONS OF SOUNDS. 225 

monic sound in some cases of mitral lesions is very 
marked. The pulmonic sound is sometimes loud, 
while the aortic sound is suppressed. 

Increased tension of the pulmonary arterial system 
may increase the intensity of the pulmonic sound, 
irrespective of hypertrophy of the right ventricle. 
This increased tension is incident to certain pul- 
monary affections — pneumonia, pleurisy, asthma, 
etc. This sound is also intensified in cases of func- 
tional palpitation and excitation of the heart by 
exercise and emotional excitement. 

In comparing the aortic and the pulmonic sound 
in disease, as in health, it is to be assumed that the 
anatomical relations of the aortic and the pulmonary 
artery to the second intercostal space on either side, 
close to the sternum, are not materially altered, and 
that the lungs are free from lesions in consequence 
of which the conduction of the sound on either side 
is abnormal. 

Returning to the systolic group of sounds, the 
mitral and the tricuspid sound may be studied sepa- 
YSitely. "With the stethoscope applied at or a little 
to the left of the apex, the valvular sound which is 
heard is derived from the mitral valve. On the 
other hand, if the stethoscope be applied at or near 
the right lower border of the heart, the valvular sound 
is derived from the tricuspid valve. E^otable weak- 
ness or suppression of the mitral sound, as compared 
with the tricuspid, represents impairment of the 
function of the mitral valve, and, per contra, notable 
weakness or suppression of the tricuspid sound de- 
notes impairment of the function of the tricuspid 
valve. Allowance in this comparison is to be made 



226 THE HEART. 

for a normal disparity, the mitral sound being louder 
than the tricuspid in health. 

BedupUcation of Heart-sounds. — The sounds of the 
heart are said to be reduplicated when either the 
systolic or the diastolic sounds are repeated, or when 
both occur twice before the long pause or interval. 
Considering the heart-sounds as two-fold, that is, 
systolic and diastolic, and as represented by the 
whispered words Lub-dup, reduplication of the sys- 
tolic sound is expressed by Lublub-dup, of the 
diastolic by Lub-dupdup, and of both by Lublub- 
dupdup. 

Clinically, reduplication of the diastolic is ob- 
served much more frequently than reduplication of 
the systolic sound. In other words, the pulmonic 
and aortic sounds, instead of being synchronous, 
occur in succession. This may occur when the sys- 
tolic sounds occur synchronously. The explanation 
is, that from increased tension of either the systemic 
or the pulmonic arteries (oftener the latter), the 
recoil of the arterial coats after the systole, and the 
extension of the sigmoid valves, take place, in one 
artery sooner than in the other. If both the systolic 
and the diastolic sounds be reduplicated, the explana- 
tion which seems most rational is, that the two ven- 
tricles contract, not in exact unison, but that one 
contracts a little before the other. In systolic redu- 
plication the mitral and the tricuspid sounds occur 
in succession instead of occurring synchronously. 
The sound of impulsion is not reduplicated. 

There is a form of functional disorder which may 
be confounded with reduplication of both sounds of 
the heart. In this disorder, with every alternate 



CARDIAC MURMURS. 1^27 

revolution of the heart, the sounds arc weak, and 
the ventricular systole is not represented by a radial 
pulse, the force of the contraction of the ventricle 
being insufficient to cause an appreciable pulsation 
in the remote arteries; hence, the heart-sounds 
occur twice for each pulse at the wrist. Under these 
circumstances, however, the carotid pulse may gen- 
erally, if not always, be felt with the weak, as well 
as with the stronger, ventricular contraction, and in 
this way the error of confounding the disorder with 
reduplication may be avoided. 

Keduplication of the heart-sounds may occur in 
connection with cardiac lesions, or there may be no 
evidence of any organic afiection. In the latter case 
the anomaly falls properly among the varied forms 
of functional disorder of the heart. Whether, or 
not, it be connected with lesions, it has no important 
pathological significance. It is usually of temporary 
duration. 

Cardiac Murmurs. 

All adventitious abnormal sounds which are added 
to the heart-sounds, are embraced by the term cardiac 
murmurs. Let it be borne in mind that, conven- 
tionally, the murmurs are never abnormal modifica- 
tions of the heart-sounds, but always newly produced 
sounds, and they always represent morbid conditions 
of either the heart or the blood. When due to 
morbid conditions of the blood, they are called in- 
organic, anaemic, or hsemic murmurs, and when they 
represent valvular lesions or changes within the 
heart, they are distinguished as organic murmurs. 

The murmurs may be distributed into three groups 



228 THE HEART. 

after differences in quality, namely : 1st, soft ; 2d, 
rough; and, 3d, musical murmurs. The soft mur- 
murs resemble the sound produced by air from the 
nozzle of a pair of bellows, and, hence, are often 
called bellows murmurs. Murmurs are said to be 
rough when their qualities may be expressed by such 
terms as rasping, grating, creaking, croaking, etc. 
They are called musical when the sound is a musical 
note. The bellows murmurs are the most frequent, 
and the musical are more rare than the rough mur- 
murs. The quality of a murmur does not in general 
invest it with any special pathological or diagnostic 
significance. The murmurs vary in pitch, being 
either relatively high or low. The variations in 
pitch are useful in aiding to discriminate different 
coexisting murmurs. 

This account of murmurs applies to those produced 
at the orifices or within the cavities of the heart. 
They are distinguished as endocardial murmurs. 
Adventitious sounds are, however, produced upon 
the external surface of the heart. These constitute 
exocardial, pericardial, or friction murmurs. 

Endocardial murmurs are produced by blood- 
currents pursuing either a normal or an abnormal 
direction. With a familiar knowledge of these cur- 
rents, and of their relations with the heart-sounds, 
the several endocardial murmurs are very easily 
understood, as regards points involved in their dif- 
ferentiation from each other. The student is, there- 
fore, advised first to become acquainted with the 
blood-currents in health and in disease. Directing 
the attention to the left side of the heart, there are 
two normal blood-currents, namely, the current from 



CARDIAC MURMURS. 



229 



the left auricle to tlie left ventricle, and the current 
from the left ventricle into the aorta. These may 
be distinguished as the direct currents. The first is 
the mitral direct current, and the second is the aortic 
direct current. Two abnormal currents may occur 
in the left side of the heart. These currents can 
only take place when the valves are rendered incom- 
petent by lesions. The incompetency of the valves 

Fig. 13. 




Diagram represeiiting,tlie Abuormal Blood-ciiiTents. 

Plain arrows represent currents in right side of heart. Dotted arrows : 
currents in left side of heart. 



allows of regurgitation, and these abnormal currents 
may be distinguished as the regurgitant currents. 
One of these is a current backward from the left 
ventricle into the left auricle, owing to incompetency 
of the mitraJ valve ; this is the mitral regurgitant 
current. The other is a current backwards from 
the aorta into the left ventricle, arising from incom- 
20 



230 



THE HEART. 



petency of the aortic valve ; this is the aortic regur- 
gitant current. (Figs. 13 and 14.) 

What are the relations of the four currents in the 
left side of the heart with the heart-sounds ? The 
mitral direct current takes place v^hen the auricles 

Fig. 14. 




Diagram representing the Normal Blood-currents. 

Pliiin arrows represent currents in right side of heart. Potted arrows represent 

currents in left side of heart. 

contract. The contraction of the auricles precedes 
the ventricular systole. The ventricular systole is 
synchronous with the systolic sounds of the heart. 
The mitral direct current, therefore, takes place just 
before these sounds. It begins after the diastolic 
sounds, and continues until it is suddenly and com- 
pletely arrested by the contraction of the ventricle. 
It is, therefore, presystolic. It is obvious that the 
current cannot continue during the ventricular con- 
traction, that is, when the first systolic sounds of the 
heart are produced. The mitral regurgitant current 



CARDIAC MURMURS. 231 

is caused by the contraction of the ventricle ; the 
current, therefore, must take place with the systolic 
sounds of the heart. The aortic direct current, being 
caused by the contraction of the left ventricle, takes 
place with the systolic sounds of the heart. It is, 
therefore, coincident with the mitral regurgitant 
current. The aortic regurgitant current is caused 
by the recoil of the arterial coats upon the column 
of blood within the aorta directly after the ven- 
tricular systole, and as this recoil causes the diastolic 
aortic sound of the heart, the current and this sound 
must be coincident. 

Recapitulating the relations of the four currents 
with the heart-sounds, the aortic direct and the 
mitral regurgitant take place with the systolic sounds 
— they are systolic currents. The mitral direct cur- 
rent precedes the systolic sounds — it is presystolic; 
and the aortic regurgitant current takes place with 
the diastolic sound — it is diastolic. 

Analogous blood-currents take place in the right 
side of the heart, and have corresponding relations 
with the heart-sounds. These currents are the tri- 
cuspid direct, the tricuspid regurgitant, the pulmonic 
direct, and the pulmonic regurgitant. The pulmonic 
regurgitant is exceedingly rare in consequence of the 
infrequency of pulmonic lesions; but the tricuspid 
regurgitant is not uncommon, and occurs without 
valvular lesions or enlargement of the heart when 
the right ventricle is distended with blood, consti- 
tuting what has been called the " safety valve func- 
tion " of the tricuspid orifice. 

Organic endocardial murmurs are produced by 
the foregoing direct and regurgitant blood-currents. 



232 THE HEART. 

and they are designated by the same names, that is, 
they are either direct or regurgitant. Thus, there 
are produced in the left side of the heart — the side 
in which valvular lesions are seated in the great 
majority of cases — a mitral direct murmur, a mitral 
regurgitant murmur, an aortic direct murmur, and 
an aortic regurgitant murmur. In the right side of 
the heart there may be produced corresponding 
murmurs, namely, a tricuspid direct, a tricuspid 
regurgitant, a pulmonic direct, and a pulmonic 
regurgitant. It remains to point out the means of 
differentiating these several murmurs aside from 
their relations with the heart-sounds. 

Mitral Direct or Presystolic Murmur. — This murmur 
begins after the diastolic sounds and ends abruptly 
with the systolic sounds. Almost invariably, this 
murmur is rough in quality ; occasionally, it is a soft 
bellows murmur. When rough, it is often quite 
loud. The rough quality is peculiar ; it is suggestive 
of vibration, and may be imitated by causing the 
lips or the tongue to vibrate with the breath in ex- 
piration. I state the mechanism of this murmur, 
inasmuch as the explanation is original with me, and 
has not been as yet generally accepted. It is caused 
by the vibrations of the mitral curtains, and takes 
place when these curtains are united at their sides, 
leaving a narrow buttonhole-like orifice through 
which the mitral direct current of blood flows. 
Throwing the lips into vibration with the breath, 
represents not only the characteristic quality of the 
murmur, but the mode of its production. The 
physical conditions which are requisite generally for 
its production are a narrowed mitral orifice, and 



CARDIAC MURMURS. 233 

flaccidity of the mitral curtains. The latter of these 
conditions does not always exist in cases of mitral 
obstructive lesions, and, hence, the murmur by no 
means always accompanies these lesions. "When it 
is considered how loud a blubbering sound may be 
produced by the vibration of the lips with a feeble 
current of air, it is not difficult to understand that 
an intense murmur may be caused by a current of 
blood propelled by the comparatively weak contrac- 
tion of the auricle. This murmur may be produced 
artificially, and the mechanism of its production 
demonstrated in the following manner : Take a small 
India-rubber bag with thin walls — such as that which, 
when inflated, makes a balloon for children ; attach 
the opening to the efterent tube of a Davidson's 
syringe; make a small orifice opposite to the at- 
tached opening of the bag; immerse the bag in a 
basin of w^ater, and then force a current of water 
into the bag. With a binaural stethoscope, the pec- 
toral extremity applied lightly to the bag, a murmur 
caused by the flow of water from the bag into the 
basin, is heard, resembling as closely as possible the 
usual presystolic murmur. 

Peter states that the production of a mitral pre- 
systolic murmur requires hypertrophy of the left 
auricle.^ This may be doubted, in view of the fact 
to be stated in the next paragraph. Hypertrophy of 
the auricle, however, accompanies the lesion which 
the murmur represents, when the murmur is organic, 

A mitral direct murmur may be produced without 
mitral lesions, the murmur having the same char- 

1 Traite des Maladies da Coeur, Paris, 1883. 
20* 



.234 THE HEART. 

acteristic quality as when lesions exist, and being 
also quite loud. This fact, based on clinical proof, 
was stated by me many years since, together with 
the explanation. The murmur occurs when there 
are aortic lesions which permit regurgitation. Under 
these circumstances, at the time when the auricular 
contraction takes place, the left ventricle is already 
filled with blood, the mitral curtains are floated out 
so as to be in contact with each other, and the mitral 
direct current passing between the curtains throws 
them into vibration precisely as when the orifice is 
narrowed. The vibration of the lips when lightly 
in contact, caused by the expired breath, illustrates 
the manner in which a mitral direct murmur takes 
place without mitral lesions. The murmur thus 
occurring without mitral lesions is not constant; it 
is now present and now absent, depending, as it 
does, on the quantity of blood within the left ven- 
tricle at the time of the contraction of the auricle. 
It follows from what has just been stated, that a 
mitral direct murmur is not always a sign of mitral 
obstructive lesions when there is free aortic regur- 
gitation. 

This murmur is limited to a circumscribed space 
around the apex of the heart. However loud the 
murmur may be in this situation, it is lost within a 
short distance from the apex.^ 

It is proper to state that some observers do not 
attribute a presystolic murmur to the mitral direct 
current. Donaldson, Leaming, and others, suppose it 
to be, in fact, a mitral systolic murmur, the murmur 

1 Professor Janeway states that in rare instances he has heard 
this murmur over the lower part of the scapula. 



cAediac murmurs. 235 

reaching the ear before the systolic sounds are heard. 
The occurrence of this murmur in connection with 
aortic lesions, the mitral valves being sound, Keyt 
explains by supposing that the murmur may be pro- 
duced at the aortic orifice, the murmur being heard 
before the systolic sounds. There is, however, a 
very general agreement that the murmur is correctly 
called a mitral direct murmur, 

A mitral direct murmur is never due to a morbid 
condition of the blood. Although it occurs without 
mitral lesions, yet, inasmuch as its occurrence then 
requires the existence of aortic regurgitant lesions, 
it cannot be said to be an inorganic murmur. 

A mitral direct murmur, as has been stated, does 
not alw^ays accompany mitral lesions. If the mitral 
curtains are fixed or made rigid by calcification, so 
that vibration with the mitral direct current of blood 
does not take place, either the murmur is wanting, 
or its usual characteristic quality is absent. Feeble- 
ness of the auricular contraction from dilatation or 
over-distention of the auricle with blood, may cause 
the murmur to disappear. Under these circum- 
stances the murmur may be sometimes present and 
at other times absent. Cardiac vibration or thrill 
is a physical sign which accompanies often a well- 
marked characteristic presystolic murmur, but this 
sign may occur in connection with other valvular 
lesions. The thrill is presystolic in time when it 
accompanies the presystolic murmur. The thrill is 
systolic when it accompanies an aortic direct or a 
mitral regurgitant murmur, and diastolic when it 
accompanies an aortic regurgitant murmur. 



236 THE HEART. 

Mitral Diastolic Murmur. — A murmur may be 
produced by the mitral direct current of blood prior 
to the contraction of the left auricle ; in other words, 
occurring before the presystolic murmur. From the 
latter this murmur may be distinguished as a mitral 
diastolic murmur. The flow of blood from the 
auricle into the ventricle begins directly the ven- 
tricular systole ends. This may be said to be a 
passive current until the auricle contracts. The 
contraction of the auricle makes the current active. 
Xow, under certain organic conditions, the passive 
current produces a murmur which, in point of time, 
is diastolic, that is, directly following the diastolic 
sounds of the heart. The murmur occurs at the 
same time as an aortic regurgitant murmur. From 
the latter it is to be discriminated by its localization 
at or near the apex of the heart, and by the absence 
of a diastolic murmur at the base. It may precede 
the characteristic presystolic murmur, differing from 
the latter in quality, or the diastolic murmur, with- 
out the characteristics which usually belong to the 
presystolic murmur, may continue during the whole 
of the long pause of the heart. 

The mitral diastolic murmur (as this murmur may 
be called) is doubtless rare, but less so, perhaps, than 
may be supposed, for two reasons: first, it is apt to 
be overlooked ; and, second, when recognized it has 
been customary to refer it to the aortic orifice. The 
frequency of the murmur and the particular physical 
conditions under which it is present, are to be de- 
termined by further clinical study. 

Mitral Regurgitant Murmur — Mitral Systolic Noii- 
regurgitant, or Intra-ventricular Murmur. — The mitral 



CARDIAC MURMURS. 237 

regurgitant murmur, synchronous with the systolic 
sounds, that is, a systolic murmur, may be soft, 
rough, or musical in quality, its intensity and pitch 
being variable. Aside from its relation with the 
systolic heart-sounds, it is distinguished by having 
its maximum of intensity at or near the situation of 
the apex-beat. It may be limited to a circumscribed 
area, and if heard at a distance from the apex it is 
best transmitted laterally around the left side of the 
chest, on the line of the apex. It is often heard on 
the posterior aspect of the chest near the lower angle 
of the left scapula, and not infrequently in the cor- 
responding situation on the right side. 

A murmur with the systolic sounds of the heart 
heard v/ithin a limited area at the apex, may be due 
to roughness of the endocardial membrane without 
mitral incompetency, and, consequently, without a 
mitral regurgitant current. This is a mitral systolic 
non-regurgitant murmur. It may, also, be called an 
intra-ventricular murmur, being produced, not at 
the mitral orifice, but within the ventricle. This 
murmur cannot always be discriminated from a 
feeble mitral regurgitant murmur. If, however, a 
mitral murmur be conducted laterally for some dis- 
tance to the left of the apex, and if it be heard on 
the back, it probably denotes mitral regurgitation. 
A mitral systolic, non-regurgitant, or intra-ventricu- 
lar murmur is the murmur present in endocarditis. 
It may be caused, as has been demonstrated by ray 
colleague. Prof. Janeway, by a tendinous cord ex- 
tending from the inner wall on one side to the oppo- 
site side of the ventricular cavity. This occurs as a 
congenital anomaly. Aneurism of the heart may 



238 THE HEART. 

be so situated as to give rise to a murmur simulating 
a mitral sj^stolic murmur. Cardiac aneurism, how- 
ever, is exceedingly rare. Aneurism of the thoracic 
aorta may cause a murmur which, transmitted 
through the heart, simulates a mitral systolic 
murmur. 

The impulse of the apex of the heart against the 
adjacent portion of the lung sometimes forces the air 
from the air-vesicles sufficiently to give rise to a 
blowing sound occurring with each ventricular sys- 
tole. This is liable to be confounded with an endo- 
cardial murmur. Produced in the way just stated, 
it is heard only during the act of inspiration, and 
especially at the end of this act. 

A mitral systolic murmur is rarely, if ever, due to 
an abnormal condition of the blood, without any 
anatomical change in the valve or endocardial mem- 
brane. Conditions of the blood, however, which 
are favorable for the production of inorganic mur- 
mur may intensify this murmur as well as any of the 
organic murmurs. 

It has been conjectured that a mitral systolic mur- 
mur may be produced by a purely functional incom- 
petency of the mitral valve, permitting a mitral 
regurgitant current, no actual lesion of the valve or 
the mitral orifice existing. In this way are explained 
the occurrence of a mitral systolic murmur and its 
disappearance after a remoter duration, without 
other evidence of endocarditis or any organic afi'ec- 
tion of the heart. It does not enter into the scope 
of this work to discuss the validity of this explana- 
tion. The fact, however, that a mitral systolic mur- 
mur may exist, continue for weeks or months, and 



CARDIAC MURMURS. 239 

even for years, and disappear, the murmur being 
neither accompanied nor followed by signs or symp- 
toms denoting organic disease, is an important fact 
to be borne In mind with reference to diagnosis and 
prognosis. The temporary occurrence of this mur- 
mur in chorea has been attributed to functional 
incompetency of the valve due to irregular contrac- 
tion of the papillary muscles. 

Aortic Direct Murmur. — This murmur, like the 
mitral systolic murmurs, occurs with the systolic 
sounds of the heart. Of the organic murmurs on 
the left side of the heart, the mitral systolic murmurs 
and the aortic direct murmur are synchronous, the 
others having different relations with the heart- 
sounds. The aortic direct murmur differs from the 
mitral systolic murmurs in having its maximum of 
intensity at the base of the heart. It is loudest in 
the second intercostal space near the sternum. As 
a rule, it is louder in this intercostal space on the 
right than on the left side ; this rule, however, has 
frequent exceptions. It is transmitted better and 
further upward than downward. It is always heard 
over the carotid artery ; and it is sometimes louder 
over this artery than at the base of the heart. As a 
murmur may be produced within the carotid artery, 
it is desirable to determine, when a systolic murmur 
is heard at the base, whether the carotid murmur is 
a transmitted murmur or not. This point is to be 
settled by comparing the murmur over the carotid 
with the murmur at the base, as regards quality and 
pitch. If the quality and pitch of the murmur in 
the two situations be the same, it is fair to consider 
the murmur in the carotid as not produced within 



240 THE HEART. 

the artery, but conducted by the blood-current from 
the aortic orifice. 

An aortic direct murmur is frequently inorganic. 
It is to be considered as such when it is not asso- 
ciated with an aortic regurgitant murmur; when the 
heart is not enlarged ; when anaemia is shown by the 
presence of murmurs in the large arteries; and when 
there is the venous hum^ in the neck — these physical 
evidences of anaemia being associated generally, not 
invariably, with pallor, and with symptoms pointing 
to impoverishment of the blood. Moreover, an in- 
organic murmur is very rarely rough, and it is vari- 
able in its occurrence, being at one time present and 
at another time absent, whereas, an organic murmur 
is, in general, constant. Associated with other evi- 
dence of anaemia, an aortic direct murmur may, 
nevertheless, be organic, but, under the differentiating 
circumstances just stated, the lesion represented by 
the murmur, if the murmur be organic, must be in- 
nocuous, so that it is not of great practical impor- 

* To obtain the venous hum {bruit de diable), cause the patient 
to turn the head as far as practicable to the left, and apply the 
stethoscope to the neck or the right side, near the clavicle, behind 
the sterno-cleido-mastoid muscle. Press the stethoscope with 
diiferent degrees of force before concluding that the murmur is 
wanting. The venous hum is continuous, and closely resembles 
the sound of the humming-top. Gentle pressure, with the finger 
above the stethoscope, so as to interrupt the flow of blood in the 
veins, causes the murmur at once to cease. This fact is proof of 
its being a venous murmur, A systolic murmur heard with the 
stethoscope applied to the neck, is an arterial murmur, which may 
either be produced within the artery, or transmitted from the 
aortic orifice. An arterial and a venous murmur in the neck often 
coexist. 



CAKDIAC MURMURS. 241 

tance to determine whether the murmur be or be not 
inorganic. 

Like the other organic murmurs, an aortic direct 
murmur varies in different cases in intensity, quality, 
and pitch. An organic aortic direct murmur, per se, 
does not denote always aortic obstruction. It may 
be due simply to roughness of the membrane at or 
above the aortic orifice. 

Aortic Regurgitant Murmur — Aortic Diastolic Non- 
regurgitant Murmur, or a Prediastolic Murmur. — An 
aortic regurgitant murmur occurs with the second 
diastolic sounds of the heart. It is almost always 
heard at the base of the heart, but, in some instances, 
when not appreciable at the base, it is heard a little 
below the base, namely, near the sternum on the 
left side on a level with the fourth costal cartilage. 
In some instances, however, the maximum of in- 
tensity is in a corresponding situation on the right 
side. In the latter situations it has generally its 
maximum of intensity. It is transmitted best in a 
downward direction, being often heard at the apex, 
and sometimes considerably below this point. It is 
never inorganic. It is usually not intense, low in 
pitch, and soft; but it may be loud, high, rough, or 
musical. 

A short murmur is sometimes produced by the 
retrograde movement of the blood-current within 
the aorta, the aortic valve being intact, and regurgi- 
tation not, therefore, taking place. This murmur is 
due to roughening of the lining membrane of the 
aorta by atheroma or calcareous deposit, and it is 
always preceded by an aortic direct murmur. It 
occurs directly after the systole, and ends with the 

21 



242 THE HEAiRf. 

second sound. Although of such brief duration, it 
is distinctly recognizable and distinguished from the 
preceding aortic direct murmur. I have long been 
accustomed to demonstrate this murmur in private 
teaching, and have called it an aortic diastolic non- 
regurgitant murmur. A better name is a predias- 
tolic murmur. It cannot be said to have much 
practical importance, inasmuch as the lesion giving 
rise to it is represented by the aortic direct murmur 
which precedes it. This murmur may be associated 
with a true regurgitant murmur. This is the ex- 
planation of a diastolic murmur which is rough 
before and soft after the aortic second sound. 

Coexisting Endocardial Murmurs. — The murmurs 
referable to the left side of the heart, which have 
been considered, are often found in combination; 
two or three may coexist, or all of them may be 
present. Moreover, with more or less of these mur- 
murs may be associated murmurs referable to the 
right side of the heart. Having become familiar 
with their relations with the heart-sounds, and other 
points involved in their differentiation, it is not diffi- 
cult to recognize them in combination. The mitral 
murmurs are not infrequently associated. The 
mitral direct, being presystolic, ends with the sys- 
tolic sounds, and the mitral systolic or regurgitant 
begins with these sounds ; the systolic sounds, as it 
were, divide these two murmurs. These murmurs 
almost invariably differ from each other in pitch and 
quality. The presence of both, in fact, assists, rather 
than obstructs, the recognition of each. The aortic 
direct and the aortic regurgitant murmur, also, are 
often associated. A murmur then accompanies the 



CARDIAC MURMURS. 243 

systolic and the diastolic sounds of the heart ; the 
two murmurs follow in the same rhythmical order 
as the two groups of heart-sounds. These murmurs, 
when associated, can only be confounded with peri- 
cardial friction-sounds. 

The combination of the aortic direct and the 
mitral systolic murmur alone oiFers any difficulty. 
These two murmurs have the same relation with the 
heart-sounds ; they are both systolic. How is it to 
be determined, when a systolic murmur is heard 
both at the base and apex, whether a mitral mur- 
mur is transmitted to the base, or an aortic mur- 
mur is transmitted to the apex; in other words, 
how is it to be decided whether two murmurs are 
present or only one murmur? If these two mur- 
murs coexist, generally the circumstances which 
distinguish each separately can be ascertained. 
Thus, the aortic murmur is transmitted into the 
carotid artery, and the presence of that murmur is 
then established: the mitral regurgitant murmur is 
often transmitted laterally around the chest or heard 
at the lower angle of the scapula, and then the pres- 
ence of that murmur is established. But there are 
additional points, namely, the murmur at the base 
and that at the apex generally differ sufficiently in 
pitch or quality to render it evident that there are 
two murmurs ; and generally at a situation in the 
prsecordia between the base and apex, both murmurs 
may be either lost or become notably weakened. 
Attention to these points in most instances divests 
the problem of difficulty. 

Mitral and aortic lesions are often of a character 
to give rise to only one murmur at either of these 



244 THE HEART. 

orifices. A mitral direct murmur not infrequently 
is present without the mitral regurgitant, and the 
reverse of this is frequent. So, either an aortic direct 
or an aortic regurgitant murmur may exist without 
the other. 

Tricuspid Direct Murmur. — The lesions which are 
requisite for this murmur very rarely occur at the 
tricuspid orifice; hence, this murmur is exceedingly 
rare. It is to he distinguished from the mitral direct 
murmur by its localization being, not at the apex, 
but at the right border of the heart. The mitral 
direct and the tricuspid direct murmur may coexist; 
an instance of this kind has fallen under my observa- 
tion. In that instance a presystolic murmur, with 
the characteristic blubbering quality, was heard both 
at the apex and at the right side of the heart. 

Tricuspid Regurgitant Murmur. — This murmur is 
not of infrequent occurrence. Tricuspid regurgita- 
tion occurs often when the right ventricle is con- 
siderably dilated, without the existence of lesions of 
the valve. A tricuspid regurgitation current, how- 
ever, does not invariably give rise to an appreciable 
murmur. This fact is shown by the occurrence of a 
venous pulse in the neck, due to tricuspid regurgita- 
tion, when no murmur can be heard. 

The tricuspid regurgitant murmur, of course, 
occurs with the first or systolic sound, being systolic 
like the mitral regurgitant murmur, and the latter 
generally coexists. It is distinguished from the 
mitral regurgitant by its localization at the right 
inferior margin of the heart, and its transmission to 
the right rather than to the left. The coexistence 
of the mitral and the tricuspid regurgitant murmur 



CARDIAC MURMURS. 245 

is determined by the differences in pitch and quality 
between a systolic murmur at the apex and at the 
right margin of the heart. A venous pulse, syn- 
chronous with the first sound of the heart, points to 
tricuspid regurgitation, and, although sometimes 
present without a tricuspid regurgitant murmur, 
when present it is corroborative evidence of the 
latter.^ 

Pulmonic Direct Murmur. — A pulmonic direct 
murmur, if organic, is generally connected with con- 
genital lesions. The pulmonic direct and the aortic 
direct current of blood taking place at the same 
instant, the murmurs representing both are, of 
course, systolic. How is the pulmonic to be dis- 
tinguished from the aortic direct murmur? The 
pulmonic murmur is heard in the left second inter- 

^ Pulsation of the cervical veins is a not infrequent sign in cases 
of enlargement of the right side of the heart. The pulsation in 
the veins is visible, but verj^ rarely appreciable by the touch. It 
is to be distinguished from pulsation of the arteries of the neck. 
This is easily done by finding that pressure just above the clavicle 
sufficient to interrupt the flow of blood in the veins, but not in the 
arteries, abolishes the pulsation. The venous pulse is generally 
due to a tricuspid regurgitant current, and is therefore caused by 
the contraction of the right ventricle. It may, however, be caused 
by the contraction of the right auricle. If caused by the contrac- 
tion of right ventricle giving rise to tricuspid regurgitation, the 
venous pulse is synchronous with the carotid pulse, the systolic 
sounds of the heart, and the apex-beat. If caused by the contrac- 
tion of the right auricle, the venous pulse precedes the carotid pulse ; 
it is presystolic. A venous pulse thus may be either ventricular or 
auricular, and the differentiation is easily made. There may be 
both a ventricular and an auricular venous pulse, the one syn- 
chronous with, and the other preceding, the carotid pulse. Pulsa- 
tion is sometimes observed in other veins than those of the neck — 
the brachial, femoral, and even veins still more remote from the 
heart. 

21* 



246 THE HEART. 

costal space close to the sternum ; but this is not 
very distinctive, inasmuch as, not infrequently, the 
aortic murmur is loudest in that situation. The 
essential point of distinction is this : the pulmonic 
direct murmur is not transmitted into the carotid 
artery, whereas, the aortic direct murmur is always 
thus transmitted. If an aortic direct and a pulmonic 
direct murmur coexist, both being organic, the com- 
bination is to be ascertained by finding that the 
murmur in the second intercostal space on the right 
sitie differs from that on the left side in pitch or 
quality sufficiently to show the presence of these 
murmurs, the one on the right side being transmitted 
to the carotid artery. 

An inorganic or functional pulmonic direct mur- 
mur is of frequent occurrence in cases of anaemia. 
It is frequently associated with an inorganic aortic 
direct murmur, the presence of the two murmurs 
being evidenced by a difi^erence in pitch. The theory 
of "Waunym, that the systolic functional murmur 
heard in the left second intercostal space near the 
sternum, and generally referred to the pulmonic 
orifice, is not a pulmonic, but a mitral regurgitant 
murmur conducted by the dilated appendix of the 
left auricle, has been elaborately advocated by Dr. 
Balfour, of Edinburgh. This theory is so strained 
and fanciful, that it hardly deserves the discussions 
which it has received from others. It is certain that 
a mitral regurgitant murmur due to mitral lesions 
has its maximum of intensity at or near the apex of 
the heart. Why should a murmur hypothetically 
referred to functional incompetency of the mitral 



CARDIAC MURMURS. 247 

valve be heard above the base of the heart and not 
at the apex? 

Pulmonic Begurgitant 3Iurmur. — This murmur is 
exceedingly rare in consequence of the infrequency 
of pulmonic regurgitant lesions. It occurs, of course, 
like the aortic regurgitant, with the second or dias- 
tolic sound. Its presence can only be determined 
when other signs go to show the existence of pul- 
monic and the absence of aortic lesions. This mur- 
mur, as well as the aortic regurgitant, can never be 
inorganic, its presence being proof of a regurgitant 
current of blood from incompetency of the pulmonic 
valve.^ 

Facts of practical importance in relation to the 
endocardial murmurs, are embraced in the following 
statements : 

The question as to a murmur being organic or 
inorganic, relates chiefly, if not entirely, to the aortic 
direct and the pulmonic direct murmur, other mur- 
murs being almost invariably organic. 

Associated signs and symptoms generally warrant 
a definite conclusion whether an aortic direct or a 
pulmonic direct murmur be, or be not, organic, and 
under the circumstances which render it difficult to 
decide this question positively, a positive decision is 
not of much immediate practical consequence. 

Valvular lesions, whether obstructive, regurgitant, 
or innocuous, are so uniformly represented by mur- 
mur, that, as a rule, absence of lesions may be predi- 
cated on the absence of murmur. 

^ I have met with an instance in which it existed, and was 
attributed to pressure from without. 



248 THE HEART. 

With a practical knowledge of the cliflerent organic 
murmurs, the situation of lesions at either of the 
orifices of the heart, or their existence at two or 
more of these orifices, may be demonstratively de- 
termined. 

By means of the murmurs, with other signs, it 
may be determined demonstratively whether the 
lesions involve obstruction or regurgitation, or both, 
or, on the other hand, that they are, as regards im 
mediate pathological eflrects, innocuous. 

The murmurs do not afford definite information 
as to the amount of obstruction or regurgitation, in 
other words, as to the pathological importance or 
gravity of lesions when they are not innocuous. ISTo 
positive conclusions on this point of view are to be 
drawn from the intensity of murmurs, their pitch, or 
their quality. As a rule, murmurs which are weak, 
more than those which are loud, represent grave 
lesions. 

Pericardial or Friction Murmur. — A pericardial or 
friction murmur is produced by the rubbing together 
of the surfaces of the pericardium in the systolic and 
diastolic movements of the heart. In the vast ma- 
jority of the cases in which this murmur occurs, it 
denotes either the presence of recent lymph which 
renders the surfaces more or less adhesive, or rough- 
ening from lymph which has become dense and 
adherent; its diagnostic significance, therefore, re- 
lates almost exclusively to pericarditis. In this 
relation it is of great practical importance. 

This exocardial murmur is to be discriminated 
from the endocardial murmurs. The points involved 
in the discrimination are as follows : The murmur 



CARDIAC MURMURS. 249 

is double, that is, a murmur accompanies both the 
ventricular systole and diastole. It can, therefore, 
only be confounded with an aortic direct and an 
aortic regurgitant murmur in combination. The 
quality of the murmur is suggestive of rubbing or 
friction. It is sometimes a feeble, grazing sound; 
in other instances it is loud and rough. When 
rough, the quality is expressed by such terms as 
rasping, grating, creaking, etc. Although accom- 
panying both the systolic and diastolic sounds of the 
heart, it has not that uniform, fixed relation to these 
sounds which characterizes the aortic direct and the 
aortic regurgitant murmur; it is not in definite 
accord with the heart-sounds. Moreover, in inten- 
sity it varies with the successive movements of the 
heart, being louder with some revolutions than with 
others, in this regard differing notably from the 
endocardial murmurs. It is not heard without the 
prsecordia, as a rule, and is often limited to a part of 
the prsecordial region, whereas, certain of the endo- 
cardial murmurs, namely, the mitral regurgitant and 
the aortic direct, are often heard at a considerable 
distance from the heart. Firm pressure with the 
stethoscope and often a forced expiration intensify 
the murmur. Its source seems very near the surface 
of the chest. In this respect it differs notably from 
endocardial murmurs, the latter appearing to come 
from a certain distance within the chest. This point 
of distinction is very appreciable, especially if, as 
often happens, a friction murmur be associated with 
an endocardial murmur. 



CHAPTER VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OF THE 
HEART AND OF THORACIC ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — Valvular 
lesions, mitral, aortic, tricuspid, and pulmonic — Fatty degeneration 
and softening of the heart — Endocarditis — Pericarditis — Functional 
disorders — Thoracic aneurism. 

The morbid physical conditions incident to the 
different diseases of the heart, and the signs repre- 
senting these conditions, have been considered in the 
preceding chapter. The diseases are not to be con- 
sidered with reference to the assemblage of signs on 
which the physical diagnosis of each is to be based. 
Most of the diseases of the heart may be diagnosti- 
cated by means of physical signs. A few cardiac 
lesions do not admit of a physical diagnosis, and they 
do not, therefore, claim consideration in this work. 
The following are the affections which will form 
separate headings in this chapter: Enlargement of 
the Heart by Hypertrophy and. by Dilatation, Val- 
vular Lesions, Fatty Degeneration and Softening of 
the Heart, Endocarditis, Pericarditis, and Functional 
Disorders. Having considered these affections, the 
physical diagnosis of thoracic aneurism will be the 
concluding topic. 

Enlargement of the Heart by Hypertrophy and by 
Dilatation. — Physical exploration to determine the 
size of the heart has three objects, namely, to deter- 



ENLARGEMENT OF THE HEART. 251 

mine, first, that the size of the heart is normal, or 
second, that the heart is enlara^ed, and, third, the 
degree of enlargement. These objects are attainable 
by means of percussion and auscultation. 

The heart is of normal size when the apex-beat is 
in its normal situation, that is, in the fifth intercostal 
space, a little within a vertical line passing through 
the nipple (the linea mammillaris) ; when the super- 
ficial cardiac space is not enlarged, as shown by 
percussion and by auscultation of the voice [vide page 
206), and when percussion shows the lateral borders 
of the heart to be situated normally, namely, on the 
left side a little within the line of the nipple, and on 
the right side of a finger's breadth to the right of the 
right margin of the sternum. These points of evi- 
dence warrant a positive conclusion that the heart is 
not enlarged. 

The fact of an enlargement and its degree are de- 
terminable by an abnormal situation of the apex, 
together with an increase of the superficial cardiac 
space and extension of the lateral boundaries of the 
deep cardiac space, especially on the left side. 

In cases of slight or very moderate enlargement, 
the apex is situated a little without the linea mam- 
millaris, but not below the fifth intercostal space. A 
somewhat greater enlargement' lowers the apex to 
the sixth intercostal space, and removes it further 
without the line of the nipple. In greater degrees 
of enlargement the apex is lowered to the seventh, 
eighth, or ninth intercostal space, and generally 
further removed to the left. The lowering of the 
apex and the removal to the left, are not nniformly 
proportionate to each other. As a rule, if the right 



252 DISEASES OF THE HEART. 

side of the heart be more enlarged than the left, the 
apex is removed without the linea mammillaris fur- 
ther than when the enlargement of the left side of 
the heart predominates, and when the latter is the 
case, the apex is lowered out of proportion to its re- 
moval without that line. The relatively abnormal 
situation downward and to the left, thus, is evidence 
of the enlargement predominating in either the right 
or the left side of the heart.^ Generally the situation 
of the apex is apparent to the touch and frequently 
to the eye. In some instances, however, the impulse 
can neither be seen nor felt. How is its situation to 
be then ascertained ? Auscultation furnishes a ready 
and reliable mode of determining this point. The 
situation in which the first sound of the heart has its 
maximum of intensity, as ascertained by means of 
the stethoscope, corresponds to the situation of the 
apex. This is hardly less definite than the presence 
of an appreciable impulse. 

In determining the fact of enlargement and its 
degree by the abnormal situation of the apex, causes 
of the latter which are extrinsic to the heart are to 
be eliminated. The apex is removed to the left of 
its normal situation by enlargement of the left lobe 

1 In some diagrammatic illustrations — e. g.^ Weil and Van Dusch 
— the relatively greater removal of the apex, either to the left or 
downward, indicating that the enlargement predominates either in 
the right or the left ventricle, is represented as precisely the reverse 
of the statements here made. In these illustrations the extension 
of the area occupied by the heart is in a direction to the right if 
the right ventricle be predominantly enlarged, and to the left if 
the enlargement predominates in the left ventricle. The illustra- 
tions are based on theoretical conclusions. Clinical observation 
shows them to be erroneous. 



ENLARGEMENT OF THE HEART. 253 

of the liver, abdominal tumors, hydroperitoneum, 
the pregnant uterus, and gastric tympanites. These 
extrinsic conditions are to be excluded or due allow- 
ance made for them. In some cases in which one 
or more of these extrinsic causes of displacement 
may exist, the apex is carried into the axillary region. 
It is to be borne in mind that these causes of dis- 
placement may exist when there is more or less 
enlargement of the heart. All these causes, while 
they displace the apex to the left, do not lower, but 
tend to raise it above, its normal situation. On the 
other hand, an aneurismal or other tumor, situated 
above the heart, may press downward the organ, 
and in this way the apex is more or less lowered.^ 

The superficial cardiac space is increased in pro- 
portion as the heart is enlarged. The extent of this 
increase is easily determined by percussion and aus- 
cultation. Within this space there is notable dulness 
on percussion. The degree of dulness is greater 
than within the superficial cardiac space in health, 
and this degree of dulness is proportionate to the 
greater area in which the heart is uncovered of lung. 
It is easy to delineate by percussion on the chest the 
boundary of the anterior border of the upper lobe of 
the left lung, in other words, of the oblique line 
which is the hypothenuse of the right-angled triangle 
representing the superficial cardiac space in health 
and in disease. The area of the superficial cardiac 
space is also not less readily and precisely ascertained 
by auscultation of the voice ; the limits of the lung 
within the prsecordia are denoted by an abrupt ces- 

1 Professor Janeway states that he has known the apex lowered 
by an unusually long first portion of the aorlic arch. 
22 



254 DISEASES OF THE HEART. 

sation or notable diminution of the vocal resonance. 
In women with large mammse auscultation is more 
available for this object than percussion. The ex- 
tent to which the superficial cardiac space is enlarged 
is a good criterion of the degree of the enlargement 
of the heart. 

In proportion as the heart is enlarged, the situa- 
tion of the left border is without the linea mammil- 
laris. Its situation is determined by percussion. 
Dulness, although not great, is sufficiently distinct 
within the deep cardiac space, and the line which 
denotes the left border of the heart is easily delineated 
on the chest. This statement holds true with respect 
to the right border of the heart ; but this border, 
even when the enlargement of the heart is great, is 
removed comparatively little to the right of its nor- 
mal situation. By means of percussion the bound- 
aries of the prsecordia as enlarged by the increased 
size of the heart may be determined and measured. 
In making this statement, it is assumed that the 
lungs are not diseased, and that the chest is not de- 
formed. Shrinkage of the upper lobe of the left 
lung may enlarge the superficial cardiac space, and 
cause displacement of the heart. The latter is an 
efltect of the presence of pleuritic effusion, and it 
may follow its removal. In cases of deformity from 
spinal curvature, to determine the fact of enlarge- 
ment of the heart, or its degree, is not always an 
easy problem. 

There is a liability to error in localizing the apex 
in some cases of enlargement. Owing to the blunted 
form of the apex, especially when the enlargement 
is chiefly of the right side of the heart, the apex-beat 



ENLARGEMENT OF THE HEART. 255 

may be feeble. It is liable to be overlooked, and a 
stronger impulse in the intercostal space above the 
apex mistaken for the apex-beat. Of course, the 
lowest impulse is the apex-beat. Careful palpation, 
and finding by auscultation the spot where the first 
sound has its maximum of intensity, will prevent 
this error. 

Enlargement of the heart, and the degree of en- 
largement having been ascertained, it is to be 
determined whether hypertrophy or dilatation pre- 
dominate. If the enlargement be slight or moderate, 
it may be a question whether hypertrophy or dilata- 
tion exist alone. As a rule, if either of these two 
forms of enlargement exist without the other, it is 
hypertrophy, for, with rare exceptions, hypertrophy 
precedes dilatation. If the enlargement be very 
great, as a rule, dilatation predominates, for the 
capability of hypertrophic increase of size has its 
limit, and an increase of size beyond this limit must 
be due to dilatation. 

The signs, denoting on the one hand hypertrophy, 
and on the other hand dilatation, relate to the 
impulses of the heart and to the heart-sounds. 
With a moderate enlargement, hypertrophy is to 
be inferred from an abnormal force of the apex-beat, 
and an intensification of the systolic sounds, espe- 
cially the sound of impulsion over the apex. With 
a considerable or great enlargement, if hypertrophy 
predominate, the apex-beat may be abnormally 
strong and prolonged, but, as already stated, owing 
to its blunted form, the beat is sometimes weak and 
scarcely appreciable; the increased power of the 



256 DISEASES OF THE HEART. 

ventricular contractions, representing the hyper- 
trophy, is then to be determined by impulses in the 
intercostal spaces above the apex. These impulses 
are sometimes present in each intercostal space be- 
tween the apex and the base, and they are abnor- 
mally strong in proportion as hypertrophy predomi- 
nates. Still more marked evidence of hypertrophy 
is sometimes obtained when the hand is placed over 
the prsecordia ; a powerful heaving movement is felt. 
The increased power of the ventricular contractions 
may, in some cases, be in this way appreciated some- 
what as if the heart were held in the hand. In cases 
of considerable or great hypertrophic enlargement, 
the intensity of the sound of impulsion over the apex 
is notably increased ; it is prolonged, and its boom- 
ing quality is more marked than in health. ISTot 
infrequently it is accompanied by a metallic ringing 
sound, or tinnitus. 

Moderate enlargement by dilatation is character- 
ized by abnormal weakness of the apex-beat and of 
the systolic sounds over the apex. Cases, however, 
of simple dilatation are rare. If the enlargement be 
considerable or great, and dilatation predominate, 
all the impulses are weak, as compared with the 
cases in which hypertrophy predominates, and the 
sound of impulsion over the apex is diminished or 
nil, the feeble, short, mitral valvular sound either 
supplanting or predominating over the sound of im- 
pulsion. These points of distinction are marked in 
proportion as dilatation predominates. 

In the great majority of the cases of enlargement 
of the heart, valvular lesions coexist. These co- 
existing valvular lesions are represented by endo- 



VALVULAR LESIONS. 257 

cardial murmurs, and they may generally be excluded 
by the absence of the latter. In most of the cases 
in which enlargement exists without valvular lesions, 
it is associated with either pulmonary emphysema 
or chronic Bright's disease. 

Valvular Lesions. 

The physical diagnosis of valvular lesions embraces 
their localization at the different orifices within the 
heart, and the determination of their character as 
giving rise to obstruction and regurgitation, or of 
their innocuousness in these respects. These objects 
of diagnosis involve the endocardial murmurs and 
the abnormal modifications of the heart-sounds which 
were considered in the preceding chapter. Lesions 
at the different orifices, namely, the mitral, aortic, 
tricuspid, and pulmonic, will be considered sepa- 
rately. 

Mitral Lesions. — The lesions at the mitral orifice 
are represented by the mitral murmurs — the mitral 
direct murmur, the mitral regurgitant, the mitral 
systolic non-regurgitant or intra-ventricular, and the 
mitral diastolic murmur. Mitral obstructive lesions 
exist whenever the mitral direct murmur is present, 
with an exception already stated and explained {vide 
p. 233), namely, this murmur is present in some 
cases in which the mitral valve is intact, aortic 
lesions, giving rise to free regurgitation, existing in 
these cases. These exceptional instances are rare, 
and I am not aware that any have been reported 
except by myself. 

Mitral regurgitant lesions exist whenever a mitral 

22* 



258 DISEASES OF THE HEART. 

murmur which is truly regurgitant is present. A 
systolic murmur having its maximum of intensity at 
or near the apex, transmitted laterally for a certain 
distance beyond the apex on the left side of the chest, 
and heard on the back near the lower angle of the 
scapula, generally, if not invariably, denotes a re- 
gurgitant current ; but a systolic murmur limited to 
a small area around the apex, or to the superficial 
cardiac space, is not proof of regurgitation. A truly 
regurgitant murmur, however, may be too feeble to 
be transmitted beyond the apex ; the proof of regur- 
gitation must then be based on other evidence asso- 
ciated with the murmur, namely, on enlargement of 
the heart and abnormal modifications of the heart- 
sounds. 

Mitral obstruction may exist without incompetency 
of the mitral valve, as shown by the presence not 
very infrequently of a mitral direct, without a mitral 
regurgitant, murmur. The converse of this is of 
more frequent occurrence, that is, regurgitation may 
exist without obstruction. The absence, however, 
of a mitral direct murmur is not positive proof 
against mitral lesions, for, as has been seen, the pro- 
duction of a characteristic mitral direct murmur re- 
quires the obstruction to be caused by an adherence 
of the mitral curtains at their sides, the curtains 
being sufficiently flexible to vibrate with the passage 
of the mitral direct current of blood. If these con- 
ditions for the production of the murmur do not 
exist, there may be no murmur produced by the 
mitral direct current ; or, if a murmur be present, it 
is devoid of the usual characteristic quality. Mitral 
obstruction and regurgitation not infrequently co- 



VALVULAR LESIONS. 259 

exist, as shown by the presence of both the mitral 
direct and the mitral regurgitant murmur. A mitral 
murmur, produced by a mitral direct current, but 
diastolic in point of time, is sometimes, as has been 
seen {vide page 236), observed in connection with 
mitral lesions. The significance of this murmur, 
except that it denotes mitral lesions, is not yet 
ascertained. 

The mitral murmurs do not, jper se, denote the 
amount of obstruction or regurgitation, or of both 
combined. Information with reference to these 
points may be derived, in the first place, from a 
comparison of the aortic with the pulmonic second 
sound. The amount of obstruction or regurgitation, 
or both, is great in proportion as the aortic sound is 
weakened. Per contra, there can be but little ob- 
struction or regurgitation if the aortic and the pul- 
monic second sound preserve completely or nearly 
their normal relation to each other in respect of 
intensity. Information may, in the second place, be 
obtained by directing attention to the mitral valvular 
sound {vide page 225). In proportion as the function 
of the mitral valve is compromised by lesions, the 
mitral valvular sound at the apex will be weakened. 
In some cases this sound is lost, the sound of impul- 
sion remaining. 

Enlargement of the right side of the heart, which 
results from mitral obstructive and regurgitant 
lesions, is a criterion of the amount of obstruction 
and regurgitation taken in connection with the 
length of time in which they have existed. Hyper- 
trophic enlargement of the right ventricle intensifies 
the pulmonic second sound, and allowance must be 



260 DISEASES OF THE HEART. 

made for this modification in determining, by a 
comparison of the pulmonic and the aortic sound, 
the degree in which the latter is weakened. Atten- 
tion is to be given to the tricuspid valvular sound 
{vide page 224). The intensity of this sound is, in 
some measure, a criterion of the power of the right 
ventricular systole. 

Aortic Lesions. — Lesions are localized at the aortic 
orifice by the aortic murmurs, namely, the aortic 
direct and the aortic regurgitant murmur. Aortic 
obstructive lesions give rise to an aortic direct mur- 
mur; but it must be considered, in the first place, 
that an aortic direct murmur may bfe inorganic, and, 
in the second place, that, if the murmur be organic, 
it may be produced by lesions which occasion no ob- 
struction, and are consequently innocuous. The 
existence of obstructive lesions must be determined 
by evidence added to the presence of the murmur. 
This evidence is either diminished intensity or sup- 
pression of the aortic second sound, and enlarge- 
ment of the left ventricle. If the lesions which 
occasion obstruction are of a character to diminish 
or arrest the movements of the aortic valve, the 
aortic second sound will be either weakened or-lost. 
If valvular lesions be limited to the aortic orifice, 
the degree of enlargement of the left ventricle is a 
criterion of their pathological importance. 

Kegurgitant lesions at the aortic orifice give rise 
to an aortic regurgitant murmur. This murmur, of 
course, is always proof of regurgitation ; but the 
murmur gives no definite information concerning 
the amount of incompetency of the aortic valve. A 
loud murmur may be produced by a regurgitant 



TRICUSPID LESIONS. 261 

stream so small as to be, for the time, insignificant ; 
and, on the other hand, a large regurgitant current 
may give rise to a feeble murmur. The extent to 
which the valve is damaged by the lesions, is to be 
determined, first, by either weakness or suppression 
of the aortic sound, and, second, by the degree of 
enlargement of the left ventricle. 

Aortic obstructive and regurgitant lesions are 
often associated. An aortic direct and an aortic 
regurgitant murmur are then both present, with a 
weakened aortic sound or its suppression, and en- 
largement of the left ventricle according to the 
amount of the obstruction and regurgitation, to- 
gether with the length of time during which the 
latter have existed. These effects, and not the 
intensity, nor the pitch, nor the quality of the 
murmurs, are indicative of their pathological im- 
portance. 

Mitral and aortic lesions often coexist, giving rise 
to two, three, or four of the obstructive and regur- 
gitant murmurs in the left side of the heart. In 
addition to the murmurs in these cases, the effects of 
the combined lesions are shown in the modification 
of the heart-sounds, and enlargement of both sides 
of the heart. 

Tricuspid Lesions. — Tricuspid obstructive lesions 
are exceedingly rare. A few instances of the kind 
of obstruction which is represented by a tricuspid 
direct or presystolic murmur, have been reported. 
One instance has fallen under my observation. In 
this case, as in the other instances which have been 
reported, the tricuspid were associated with mitral 
lesions : hence, in localizing an obstructive lesion at 



262 DISEASES OF THE HEART. 

the tricuspid orifice, the presence of the presystolic 
murmur on each side of the heart, that is, the coex- 
istence of mitral and tricuspid direct murmur is to 
be determined. This point has already been con- 
sidered {vide page 244). 

Tricuspid regurgitation is not uncommon. Gen- 
erally the insufficiency is caused by dilatation of the 
right ventricle occurring as an effect of mitral regur- 
gitant or obstructive lesions. Tricuspid regurgita- 
tion is not always represented by murmur; and 
when a tricuspid regurgitant murnmr is present, it 
is to be discriminated from a coexisting mitral re- 
gurgitant murmur. This point has been considered 
[vide page 244). A sign of free tricuspid regurgita- 
tion with hypertrophy of the right ventricle, is pul- 
sation of the liver, which may be seen and felt. 
This pulsation is sometimes notably strong. If the 
liver be enlarged, the pulsation may be communi- 
cated to the greater part of the abdomen, and its 
force may be suggestive of aneurism of the ab- 
dominal aorta. Pulsation of the liver may be ob- 
served when there is no jugular pulse nor notable 
turgescence of the cervical veins. 

Pulmonic Lesions. — As compared with aortic 
lesions, these are of infrequent occurrence, and they 
are generally congenital. Lesions giving rise to a 
pulmonic direct murmur may be localized by differ- 
entiating this murmur from the aortic direct mur- 
mur (vide page 245). It is to be considered that an 
inorganic pulmonic direct murmur is not infrequent. 
Pulmonic regurgitant lesions can only be diagnosti- 
cated by determining that a murmur is produced at 



FATTY DEGENERATION OF THE HEART. 263 

the pulmonic and not at the aortic orifice {vide page 
247). 

Fatty Degeneration, Myocarditis, and Softening of the 
Heart. — Fatty degeneration of the heart is not rep- 
resented by any distinctive signs, but, nevertheless, 
the physical diagnosis, taking into account the 
clinical history, may be quite positive. The signs 
are those which denote persistent muscular weak- 
ness of the heart. The apex-beat, if appreciable, is 
feeble. The intensity of the heart-sounds is dimin- 
ished, and especially the intensity of the systolic 
sounds. The sound of impulsion and even the 
mitral valvular sound may be suppressed over the 
apex. The sound of impulsion is especially im- 
paired or lost, the systolic sound which is heard 
being chiefly or exclusively the mitral valvular 
sound. This sound is short and valvular, in quality 
like the diastolic sound. JSTow these evidences of 
weakened muscular power may occur when the 
weakness is merely functional, and when the heart 
is enlarged by predominant dilatation. But func- 
tional weakness is generally transient, and is suffi- 
ciently explained by the existence of other than 
cardiac disease. Enlargement by dilatation is 
readily determined by physical signs. If the heart 
be but little, or not at all, enlarged, and pathological 
conditions adequate to explain diminished muscular 
power irrespective of cardiac disease be excluded, 
and at the same time the signs being connected with 
diagnostic symptoms, the existence of fatty degen- 
eration may be determined with much confidence. 

Fatty degeneration may coexist with valvular 
lesions and enlargement of the heart. The physical 



264 DISEASES OF THE HEART, 

diagnosis of fatty degeneration under these circum- 
stances is not a simple problem. A probable diag- 
nosis may be made when the amount of enlargement 
seems insufficient to account for the signs denoting 
muscular weakness of the heart, and when symptoms 
belonging to the clinical history point to fatty de- 
generation. 

Softening of the muscular structure of the heart, 
occurring in myocarditis, in continued fever, and 
other general diseases, is denoted by the same signs 
which are embraced in the physical diagnosis of 
fatty degeneration, the' most marked evidence being 
notable weakness of the systolic valvular sounds, 
and especially weakness or suppression of the sound 
of impulsion. 

Endocarditis. — The physical diagnosis of endocar- 
ditis relates especially to its occurrence in connection 
with articular rheumatism. The diagnostic sign is 
a mitral systolic non-regurgitant murmur {vide page 
205). The presence of this murmur, however, in a 
case of rheumatism, is not positive proof of an ex- 
isting endocarditis, more especially if the patient 
have previously had articular rheumatism, because 
an endocarditis developed in a previous attack may 
have left a permanent murmur. If the murmur be 
a mitral regurgitant murmur, and the heart be en- 
larged, it is quite certain that endocarditis has pre- 
viously occurred. The positive proof is the pro- 
duction of the murmur during an attack of rheu- 
matism, when previous examinations made after the 
commencement of the rheumatic attack, had shown 
that there was no mitral murmur. An aortic direct 
murmur, in cases of rheumatism, is not evidence of 



PERICARDITIS. 26<) 

endocarditis, because in many cases of rheuraatisnA 
this murmur occurs and is to be regarded as in- 
organic. 

In the variety of endocarditis known as ulcerative, 
occurring in the course of infectious or septic dis- 
eases, and sometimes without any known patholo- 
gical connection, an aortic murmur may be devel- 
oped, with or without a coexisting mitral murmur, 
owing to the soft masses present on the valves. 

Endocarditis is probably of frequent occurrence as 
secondary to mitral and aortic valvular lesions; but, 
under these circumstances, a physical diagnosis is 
impracticable. 

Pericarditis. — The physical diagnosis of pericarditis 
in the first stage, that is, prior to the efi*usion of 
liquid, is to be based on a pericardial friction mur- 
mur. Fortunately for diagnosis, this murmur is 
uniformly present. Its characters as contrasted with 
endocardial murmurs have been stated [vide page 
214). The presence of a pericardial friction mur- 
mur, in connection with symptoms denoting peri- 
carditis, renders the diagnosis quite positive. There 
is, however, one liability to error. In some cases of 
pleurisy or pneumonia with pleuritic inflammation, 
the movements of the heart occasion a rubbing to- 
gether of the roughened pleural surfaces, and in this 
way a cardiac pleural friction murmur is produced. 
This may be single or double, and when double, it 
simulates the murmur produced within the pericar- 
dia] sac. It is limited to the border of the heart, and 
is neither accompanied nor followed by pericardial 
effusion. Of course, the error of mistaking a car- 
diac pleural friction murmur for one produced 
23 



266 DISEASES OF THE HEAET. 

within the pericardium, can only occur when pleurisy 
exists, either as a primary aflection or as secondary 
to pneumonia. 

In the second stage of pericarditis, that is, after 
the effusion of liquid has taken place, the pericardial 
friction murmur often, but not always, disappears. 
The physical diagnosis in this stage is then to be 
based on the signs which show the presence of a 
greater or less quantity of liquid within the pericar- 
dial sac. The signs which denote pericardial eifu- 
sion, and its amount have been stated {vide page 
220). With a moderate eflusion, the apex of the 
heart is raised, and the apex-beat may be felt in the 
fourth intercostal space, and removed to the left of 
its normal situation. With considerable or large 
effusion, the apex-beat is lost, and the sounds of the 
heart are feeble and distant. The sound of impul- 
sion is lost, leaving the mitral and tricuspid sounds, 
which are short and valvular like the diastolic 
sounds. 

Increase or diminution of liquid in the second 
stage of pericarditis is readily determined by signs 
obtained by percussion and auscultation. When the 
quantity is much diminished, the friction murmur, 
if it have been suppressed, returns, and persists 
until the pericardial surfaces become agglutinated. 
I^ot infrequently, by auscultating when the body of 
the patient is inclined forward, a friction murmur 
may be heard, notwithstanding the pericardial sac 
contains a large quantity of liquid. 

In cases of chronic pericarditis with very large 
effusion, dilatation of the pericardial sac is shown 
by signs obtained by percussion and auscultation. 



FUNCTIONAL DISORDERS. 267 

There is no apex impulse, the heart-sounds are 
feeble and distant, the sj'stolic sounds being short 
and valvular, and the prsecordia may be notably 
projecting. 

A malignant morbid growth tilling the pericardial 
sac and inclosing within it the heart, may give rise 
to all the signs of pericardial eifusion, A case of 
this kind, in a young subject, has fallen under my 
observation. 

With reference to diagnosis, the etiological rela- 
tions of pericarditis should be kept in mind. These 
are acute articular rheumatism, Bright's disease, and 
either pleurisy or pneumonia. It rarely occurs in 
other connections, and, as an idiopathic affection, it 
is extremely rare. 

The presence of air and liquid within the pericar- 
dial sac gives rise to loud splashing sounds which, 
occurring when respiration is suspended, and when 
pneumo-hydrothorax is excluded, are at once diag- 
nostic of pneumo-hydropericardium. 

Functional Disorders. — Of the varied forms of 
functional disorder of the heart, some are rare, and 
others are of frequent occurrence. A rare form is 
persistent frequency of the heart's action, the pulse 
being from 100 to 120 or more per minute, for 
weeks, months, and even years. This form of dis- 
order exists in the aifection known as exophthalmic 
goitre, Graves's or Basedow's disease. It occurs, 
also, without being associated with either promi- 
nence of the eyes or enlargement of the thyroid 
body. In a rare form, the opposite of this, the ac- 
tion of the heart is abnormally infrequent, the pulse 
falling to 50, 40, 30, or less, per minute, the infre- 



268 DISEASES OF THE HEART. 

quency not being an idiosyncrasy, eit?ier congenital 
or acquired, and continuing for a limited period. 
The occurrence with every alternate revolution of 
the heart of a ventricular systole so feeble as not to 
be represented by a radial pulse, is another rare 
form, and another is a want of synchronism in either 
the contraction of the two ventricles, or of the recoil 
of the coats of the aorta and the pulmonic artery, 
giving rise to reduplication of heart-sounds {vide 
page 226). In the more common forms, the disorder 
occurs in paroxysms which are variable in duration 
and in the frequency of their occurrence, the heart, 
in the paroxysms, beating irregularly,- and often 
with intermissions, the action in some instances 
being violent and in other instances feeble or flut- 
tering. These common forms are embraced under 
the name palpitation. 

As regards the physical diagnosis, all the forms of 
disorder are in the same category; in all the func- 
tional character of the affection is determined by 
exclusion, inflammatory aflections and lesions being 
excluded by the absence of their diagnostic signs. 
In whatever way the action of the heart is disturbed, 
however great may be the disturbance, and let it be 
attended with ever so much distress or anxiety, if 
physical exploration furnish no evidence of endo- 
carditis, pericarditis, valvular lesions, enlargement 
of the heart, fatty degeneration, or heart-clot, the 
affection is to be considered as functional. If purely 
functional, the affection is unattended by danger, 
and is generally remediable, at least in the common 
forms. Hence, the very great importance of a posi- 
tive diagnosis. 



FUNCTIONAL DISORDERS. 269 

III one point of view, the physical diagnosis in 
functional disorders may be said to rest, not on 
negative, but on positive evidence. Percussion and 
auscultation afford the means, not only of excluding 
inflammatory affiections and lesions, but of demon- 
strating the fact that the organ is sound, at least as 
regards freedom from ordinary lesions. That its 
size is normal, is shown by the normal situation of 
the apex-beat, of the lateral boundaries of the prse- 
cordia, and of the area of the superficial cardiac 
space. That the valves are unaffected, is shown by 
the normal characters of the heart-sounds. These 
positive facts, taken in connection with the absence 
of morbid signs, render the diagnosis certain. More- 
over, the evidence, positive and negative, is readily 
and quickly obtained. Indeed, the time required 
for reaching a conclusion is so brief, that it is often 
politic to prolong unnecessarily the examination in 
order that a positive assurance of the soundness of 
the organ ma}^ have in the mind of the patient the 
weight which is desirable in order to secure relief 
from anxiety and apprehension. 

Functional disorders are not infrequently asso- 
ciated with lesions with which they have no essential 
pathological connection. A patient with lesions 
which are either innocuous or attended with little, 
if any, inconvenience, may suffer from disturbance 
of the action of the heart produced by causes which 
are wholly independent of the lesions. There is a 
liability, in these cases, to the error of attributing 
the disorders to the lesions, and thus forming an ex- 
aggerated estimate of the importance of the latter. 
To decide how much of the disturbed action of the 

23* 



270 DISEASES OF THE HEART. 

heart is due to a superadded functional affection, is 
not as easy as to determine that lesions do not exist. 
The decision must be based on the character, degree, 
or extent of the lesions, as evidenced by the physical 
signs. In this connection may be stated a practical 
maxim which it is well to bear in mind whether 
functional disorders exist or not, namely, valvular 
lesions rarely give rise to much inconvenience until 
they have led to enlargement of the heart ; and en- 
largement, either with or without valvular lesions, 
as a rule, does not lead to the serious effects which 
are characteristic of cardiac disease, so long as the 
enlargement is due to predominant hypertrophy and 
not to dilatation. 

Thoracic Aneurism. 

The physical conditions incident to thoracic aneu- 
rism which are concerned in the production of signs, 
are, the presence of a tumor within the chest, of 
variable size, formed by the aneurismal sac ; the 
passage of blood into the sac with each ventricular 
systole, and the expulsion of blood in the diastole by 
the recoil of the coats of the aneurism ; the size of 
the opening into the sac as affecting the quantity of 
blood which it receives with each systole ; the quan- 
tity of stratified fibrin which the sac contains ; the 
point of connection with the aorta of the aneurismal 
tumor, and the direction from this point in which 
the tumor extends, together with its relations to the 
lungs, the trachea, the primary bronchi, the intra- 
thoracic veins, the oesophagus, the recurrent laryngeal 



THORACIC ANEURISM. 271 

nerve, the sympathetic nerve, and either the innom- 
inate or subclavian artery. 

With reference to diagnosis, it is well to bear in 
mind that, in the great majority of cases, an aortic 
aneurism is connected with either the ascending 
portion, or the junction of the ascending and the 
transverse portion of the arch, and that the tumor 
generally extends to the right in a lateral or antero- 
lateral direction. The physical diagnosis is more 
easily made when the aneurismal tumor is thus con- 
nected. The signs are less available if the aneurism 
arise from the transverse or descending aorta, and 
especially if the tumor extends in a direction down- 
ward or backward. 

An aneurismal tumor which has made its way 
through the walls of the chest, or which, without 
perforation, causes a circumscribed bulging obvious 
to the eye and touch, presents the following diag- 
nostic signs : An impulse is seen and felt which is 
synchronous with the ventricular systole. The force 
of the impulse is variable, depending, aside from the 
force with which the left ventricle contracts, upon 
the size of the orifice between the sac and the artery, 
and the quantity of fibrin which the sac contains. A 
vibration or thrill with each impulse is sometimes a 
marked sign, but is often wanting. Frequently, but 
by no means constantly, a systolic murmur is heard 
over the tumor, and there may be also a diastolic 
murmur produced by the passage of blood from the 
sac. The heart-sounds are transmitted to the tumor 
with more or less increased intensity. There is 
notable dulness on percussion over an area corre- 
sponding to the space within the chest which the 



272 DISEASES OF THE HEART. 

tumor occupies. If the tumor be of considerable 
size, it may produce condensation of lung around it; 
the area of dulness on percussion will be in this way 
extended beyond the limits of the tumor. Under 
these circumstances, bronchial respiration and bron- 
chophony ma}^ be produced. If the aneurismal sac 
be beneath the integument, there may be to the 
touch a sense of fluctuation. 

With the foregoing signs, the physical diagnosis 
scarcely admits of doubt. Some of the signs may be 
produced by a tumor, not aneurismal, so situated as 
to receive and conduct the aortic impulse. The 
chances of a tumor being so situated as to simulate 
the signs of an aneurism are few. I have met with 
a case of empyema in which perforation of the chest 
took place in the second intercostal space on the 
right side of the sternum, giving rise in this situation 
to a fluctuating tumor which had a strong pulsation. 
On a superficial examination the case seemed clearly 
one of aneurism ; but an examination of the chest 
showed the right pleural cavity to be filled with 
liquid, and a puncture in the axillary region gave 
exit to a large quantity of pus, the pulsating tumor 
disappearing after a certain quantity of the purulent 
liquid had escaped. I have met with a similar pul- 
sating tumor, incident to empyema, on the posterior 
aspect of the chest. 

When, from its small size or its situation, an 
aneurismal tumor does not come into contact with 
the thoracic wall, and when it is situated beneath 
the sternum, signs obtained by palpation and inspec- 
tion being absent, the physical diagnosis is less easy. 
Important signs are, dulness within a circumscribed 



THOEACIC ANEURISM. 273 

space situated in the course of the aorta; an abnor- 
mal transmission of the heart-sounds within this 
space, and the presence of murmurs. These signs 
are not always available, and when present they are 
not sufficient for a positive diagnosis. Other physi- 
cal evidence and the presence of certain symptoms 
render the existence of aneurism highly probable 
either with or without the foregoing signs. If an 
aneurismal tumor press upon the trachea, it occa- 
sions a tracheal rjile, or stridor, together with 
weakness of the respiratory murmur on both sides 
of the chest. If the tumor press upon a primary 
bronchus, it occasions diminished or suppressed re- 
spiratory murmur on one side, and increased respira- 
tory murmur on the other side of the chest. These 
physical signs should always lead to a suspicion of 
aneurism in a person forty years of age. Symptoms 
which should excite this suspicion and lead to careful 
physical exploration for the physical signs of aneu- 
rism, are dyspnoea from spasm or paralysis of the 
muscles of the glottis, and aphonia or impairment 
of the voice without evidence of laryngitis, these 
symptoms denoting either excitation or pressure of 
the recurrent laryngeal nerve ; dysphagia from pres- 
sure upon the oesophagus; congestion of the face 
neck, and upper extremities from obstruction of the 
vena cava or the vense innominatse; inequality of 
the radial, carotid, and subclavian pulsation on the 
two sides, or the absence of pulsation on one side, 
and contraction of one of the pupils. These symp- 
toms not only render probable the existence of 
aneurism, but indicate its situation as regards the 



274 DISEASES OF THE HEART. 

aorta and the direction in which the aneurisraal 
tumor extends. 

An aneurism may be suspected when, owing to 
shrinkage of the lung, or deformity of the chest, 
either the aorta or the pulmonary artery just above 
the heart is removed laterally from its normal 
situation or brought into contact with the walls of 
the chest in the second intercostal space, so as to 
give rise to an appreciable impulse. A murmur 
may also be present at the point of impulse. An 
error of diagnosis under these circumstances is 
avoided by finding an adequate explanation of the 
signs just noted, and by the absence of other signs 
and of symptoms which are diagnostic of aneurism. 

In conclusion, an aortic murmur, how^ever intense 
or rough, is never evidence of aortic aneurism, and, 
on the other hand, the absence of murmur is by no 
means sufficient for the exclusion of aneurism. 



INDEX. 



k BSCESS of lung, 23, 25, 185 
A Adventitious respiratory 
sounds or rales, 122 
cavernous, 134 
classification of, 122 
crepitant, 23, 131, 171 
drybroncliial,129, 158, 

163 
gurgling, 184 
indeterminate, 139 
laryngeal and tracheal, 

122 
metallic tinkling, 137, 

152 
moist bronchial, 123, 

159, 161 
pleural or friction, 21, 

135, 171, 265 
sibilant and sonorous, 

129, 163 
splashing or succussion, 

135, 138, 179, 267 
subcrepitant, 124, 125, 
126 
^Egophony, 143, 173 
Air in pleural space, 21 
Amphoric resonance, 71 

conditions causing, 72 
respiration, 115 
voice, 149 
whisper, 149 
Analysis of sounds, 38 
Aneurism, thoracic, 25, 27, 250, 

270 
Airta and pulmonary arlery, re- 
lations of, to chest- walls, 207 
Aortic direct murmur, 239, 260 
diastolic non-regurgitant 

naurmur, 241, 260 
lesions, diagnosis of, 260 
regurgitant murmur,241, 260 
Apex-beat of heart, modification 

of, 204,205, 217,251-254 
Apoplexy, pulmonary, 65, 186 



Artery, pulmonic, and aorta, 
relation of, to walls of chest, 207 
Asthma, 24, 130, 162 
Atrophy, senile, of lungs, 165, 

168 
Auscultation, definition of, 14, 74 

in disease, 98 

in health, 75, 81 

mediate and immediate, 76 

position for, 80 

rules in practice of, 79 

BASEDOW'S disease, 267 
Blood currents, aortic, 230, 
231 
direct, 229, 232 
mitral, 229 
pulmonic, 231 
regurgitant, 229 
relation of, to heart 

sounds, 230 
tricuspid, 231 
Bread, use of, to imitate pul- 
monary signs, 47, 70, 71 
Bronchi, obstruction of, 24, 27 
Bronchial rales, drv, 129,158,163 
moist, 123", 159, 161 
respiration, 105 
causes, 106 
whisper, increased, 146 
normal, 95 
Bronchitis seated in large bron- 
chial tubes, 23, 157 
in small bronchial tubes 
(capillary), 24, 159 
Broncho-cavernous respiration , 

114 
Bronchophony, 140 

whispering, 142, 146 
Bronchorrhagia, 28 
Bronchorrhcea, 23, 125 
Broncho-vesicular respiration, 

108 
Bruit de diable, 240 



276 



INDEX. 



CAPILLAEY broncliitis, 159 
Carcinoma of lung, 22, 25, 
190 
Cardiac space, superficial and 

deep, 52, 168, 204, 206 
Cavernous rale, 134 
respiration, 111 

imitation of, 113 
Cavities, pulmonary, 25, 27, 194, 

200 
Chest, anatomy and physiology 
of, 16, 207 
regional divisions of, 35, 50, 
86 
Cirrhosis of lung, 201 
Clicking rale, 131 
Cogged-wheel respiration, 120 
Collapse of lung, 22, 159 
Conditions, morbid physical, in- 
cident to dilierent dis- 
eases of the respiratory 
system, 20, 155 
summary of, 26 
physical, of the heart in dis- 
ease, 203, 215 
in health, 203, 204 
represented by amphoric 
resonance, 72 
by cracked-metal reso- 
nance, 73 
by dulness, 66 
l)y flatness on percus- 
sion, 64 
by tympanitic reso- 
nance, 68 
by vesiculo tympanitic 
resonance, 70 
Congestion, hypostatic, of lungs, 

oedema in, 189 
Coughing, signs obtained by, 152 
Cracked-metal resonance, 73 

imitation of, 73 
Crepitant rale, 23, 131, 171 

DEATH-KATTLES, 122 
Diaphragmatic hernia, 202 
Diseases of the respiratory sys- 
tem, physical conditions inci- 
dent to, 20, 154 
Dulness, 66 

conditions causing, 66 
tic, 53, 56 



"Dulness, tympanitic, 68, 200 
Duration of sounds, 33 
Dysphagia, in thoracic aneu- 
rism, 273 

ECHO, amphoric, 149 
Emphysema, diagnosis of, 
169 
pulmonary or vesicular, 
22, 27, '70, 117, 160, 
161, 163, 164 
interlobular, 23 
rhythm of respirations 
in, 167 
Empyema, 21, 169, 175 

pulsating, 176 
ICndocardial murmurs, 228, 248 
Endocarditis, diagnosis of, 264 
Exocardial murmur, 228, 248 
Expiratory sound, prolonged, 118 
Exploration, physical, dilferent 

methods of, 13 
Exudation in air-vesicles, 23, 27 

FISSUKES, interlobar, 18, 41, 
42 
Flatness, 64 

conditions causing, 64 
hepatic, 53, 56 
Fremitus, diminished, 151 
increased, 143, 146 
in diiferent regions, 92 
normal, vocal, 90 
suppressed, 151 
Friction murmur, pericardial, 
229 
pleuritic, 21, 135, 171, 265 

GANGEENE, pulmonary, 22, 
25, 187 
Glottis, cedema of, 156 
paralysis of, 155, 273 
spasm of, 155 
Goitre, exophthalmic, 267 
Graves's disease, 267 
Gurgling rale, 134 



H 



EAKT, abnormal impulses of, 
217 
anatomical relations of, 203 
apex beat of, 20, 204, 205, 
217, 251, 252, 254 



INDEX. 



277 



Heart, diagnosis of diseases of, 
251 
dilatation of, 217 
enlargement of, 215, 251 
fatty degeneration and soft- 
ening of, 218, 263 
first sound of, intensified, 
222 
weakened, 222 
functional disorders of, 267 
hypertrophy of, 217 
hypertrophy and dilatation 
of, 250 
signs of, 251, 255, 256 
inflammation of, 263, 264 
murmurs of, 203, 208, 227, 

249 
normal, 251 
palpitation of, 268 
physical conditions of, in 
disease, 203, 215 
in health, 203, 204 
second sound, aortic, weak- 
ened, 224 
pulmonic, weak- 
ened, 224 
softening of, 263 
sounds of, 203, 208 

abnormal modifications 
of, 221, 224 
transmission of, in 
phthisis, 199 
five in number, 214 
mechanism of, 210, 211 
mitral systolic, 213, 214, 

225 
reduplication of, 226, 

268 
tricuspid systolic, 213, 
214, 225 
valvular lesions of, 219, 257 
aortic, 260 
mitral, 257 
pulmonic, 262 
tricuspid, 261 
Hemorrhagic infarctus, 22, 65, 

186 
Hernia, diaphragmatic, 26, 27, 

202 
Hum, venous, 240 
Hydatids of lung, 22 
Hydrothorax, 21, 169, 176 



JNC 



nfarctus, hemorrhagic, 22, 



NDETERMINATE rales, 139 
farctus, 
65, 186 

Inspiratory sound shortened, 117 
Intensity of normal and abnor- 
mal sounds, differences of, 28, 
29, 46, 68 
Interrupted respiration, 120 
Interstitial pneumonia, 201 

lERKING respiration, 120 

LARYNGEAL and tracheal 
respiration, 82 
rales, 122 
voice, 89 
Laryngismus stridulus, 155 
Larynx, foreign bodies in, 156 
and trachea, aftections of, 

27, 155, 156 
tumors of, 156 
ulcers of, 156 
Lesions, valvular, of heart, 219, 
257 
diagnosis of, 257 
Liquid,"in chest, 21, 23, 26, 64 
Liver, dulness over, 53, 56 

flatness over, 53, 56 
Lobular pneumonia, 22, 159, 161 
Lobules, pulmonary, collapse of, 

22, 159 
Lung, solidification of, 22, 27, 
34, 108, 145, 146 



M 



ETALLIC tinkling, 135, 137, 
152, 179 
Mitral lesions, diagnosis of, 257 
Mitral murmurs, direct, 232 
diastolic, 236 
regurgitant, 236 
presystolic, 232 
systolic non-regurgitant or 
intra-ventricular, 286 
Murmur, aortic direct, 239, 242, 
243, 247 
aortic prediastolic, 241 
cardiac, 203, 208, 220, 227, 

232, 249 
cardiac pleural, 238, 265 
diastolic or non-regurgitant, 
241 



24 



278 



Murmur, endocardial, 228, 248 
coexisting, 242 
exocardial, 228, 248 
mitral diastolic, 236, 257 
presj^stolic, 232, 257 
mechanism of, 232 
witliout mitral lesions, 

233, 235, 257 
limits of, 234 
thrill with, 235 
mitral direct, 232 

regurgitant, 236, 257 
mitral systolic, non-regurgi- 
tant, or intra-ventri- 
cular, 236, 251 
causation, 237, 258 
normal vesicular, 84 

in the different regions, 
86 
pericardial or friction, 228, 

248 
pulmonic direct, 245 
regurgitant, 247 
regurgitant, 241 
tricuspid direct, 244 
regurgitant, 244 
vesicular diminished, 101 
causes, 103 
increased, 100 
suppressed, 103 
Murmurs, endocardial, 228, 231 
exocardial, 228, 248 
facts of importance relating 

to, 247 
groups of, 227 
hsemic, 227 

organic and inorganic, 227 
Myocarditis, 263 

aTiDEMA, pulmonary, 23, 27, 
1/ 65, 133, 161, 188 
Organs, respiratory, anatomy and 
physiology of, 16 

PALPITATION, cardiac, 268 
Pectoriloquy, 148 
Pei'cussion, analysis of sounds 
in, 46 
definition of, 14 
in health, 44 
in disease, 63 
instruments for, 44 



Percussion, modes of perform- 
ing, 45 
objects of, 46 
position for, 60, 61 
respiratory, 59 
rules in practice of, 60 
sense of resistance in, 74 
signs of disease furnished 
by, 63 
Percussors, 45 

Pericardial or friction murmur, 
228, 248, 265 
sac, liquid within, 220 
surfaces, roughness of, 220 
Pericarditis, chronic, 266 

diagnosis of, 265 
Phthisis, 22, 23, 25, 112, 193 
advanced, 194, 200 
differential diagnosis of, 199 
fibroid, 201 

groups of cases in, 193 
incipient, 193, 196, 198 
moderate, 194 

signs, direct and accessory 
of, 195 
Pitch of normal and abnormal 

sounds, 28, 29, 46 
Pleural rales, 21, 135, 171, 265 
Pleurisy, acute and chronic, 21, 
26, 35, 169 
signs of first stage of, 171 
friction sound in, 171 
signs of second stage of, 
171 
horizontal and S-shaped 
lines in, 172 
[ Pleurisy, chronic, signs of, 174 
Pleuro-pneumonia, 180 
Pleximeters, 44 

Pneumonia, acute lobar, 23, 179 
circumscribed, 186 
crepitant rale in, 180, 184 
embolic, 22, 186 
interstitial, 22, 201 
lobular, 22, 159, 161 
signs of abscess in, 185 
signs in first stage, 180 
signs of purulent infiltration 

in, 185 
signs in second stage, 181 
signs in third stage, 183 
Pneumo-hydropericardium, 267 



INDEX. 



279 



Pneumo-hydrothorax, 21 , 26, 177 
amphoric voice in, 179 
metallic tinkle in, 179 

Pneiimo-pyothorax, 177 

Pneumorrhagia, 23, 187 

Pneumothorax, 21, 27, 113, 177 

PrtBcordia, 204, 216 

Pulmonary apoplexy, 186 
gangrene, 22, 25, 187 
oedema, 23, 27, 65, 133, IGl, 
188 

Pulmonic direct murmur, 245 
lesions, diagnosis of, 262 
regurgitant murmur, 247, 
232 

Pupils, inequality of, in thoracic 
aneurism, 273 

Pyothorax, 21 



Q 



UALITY of normal and ab- 
normal sounds, 28, 80, 46 
terms denoting, 32 



RALE, cavernous or gurgling, 
134 
crepitant or vesicular, 23, 

131 
indeterminate, 139 
metallic tinkling, 137, 152 
splashing or succussion, 135, 
138, 179, 267 
Pvales, 122 

fine bubbling or subcrepi- 

tant, 124, 125, 126 
classification of, 122 
dry bronchial, 129, 158, 163 
laryngeal and tracheal, 122 
moist bronchial, 123, 159, 

161 
pitch of, 24 
pleural or friction. 21, 135, 

171, 265 
tracheal, 24, 122 
sibilant and sonorous, 129, 
163 
Kegions, anatomical relations 
of, 40 
division of chest into, 35 
sections of chest correspond- 
ing to, 36, 50, 86 
Resistance, sense of, in percus- 
sion, 74 



Resonance, absence of, or flat- 
ness, 64 
amphoric, 71 
cracked metal, 73 
diminished, or dulness, 66 
disparity of, on the two 

sides, 57 
in different regions, 50 
normal, vesicular, on per- 
cussion, 47 
vocal, over larynx and 
trachea, 89 
over chest, 90 
standard for, 56 
tympanitic, 48, 49, 68 
variations in ditferent re- 
gions of chest, 50 
vesiculo-tympanitic, 70, 165 
vocal, diminished, 150 
increased, 143 
causes of, 144 
Respiration, abnormal modifica- 
tions of, 99 
amphoric, 115 

imitation of, 116 
bronchial or tubular, 105, 272 
broncho-cavernous, 114 
broncho-vesicular, 108 
cavernous. 111 
diminished, 101,156,161,166 
harsh, 108 
indeterminate, 108 
in different regions, 86 
interrupted, 120 
metamorphosing, 114 
normal, laryngeal, and tra- 
cheal, 82 
vesicular murmur of, 84 
puerile, 100 
rude, 108 

supplementary, 100 
suppressed, 103 
vesicular murmur of, in- 
creased, 100 
vesiculo-cavernous, 115 
Respiratoi-y organs, anatomy, 
physiology of, 16 
physical conditions in- 
cident to diseases of, 
20, 26, 154 
Rhythm, respiratory, 
in emphysema, 167 



280 



INDEX. 



OIGNS, 14 

U by percussion in disease, 63 
in health, 44 
healthy and morbid, dis- 
tinctive characters of, 14, 
27 
object of, 15 

obtained by coughing, 152 
physical, definition of, 14 
respiratory, in disease, 99, 
103 et seq. 
classification of, 99 
in health, 75 
significance of, 34 

as representing physical 
conditions, 34 
vocal, in health, 89 
of disease, 140 
Softening of the heart, 263 
Sounds, diflTerences of intensity 
in, 28, 29 
in pitch, 29 
in quality, 30 
normal and abnormal, 14, 99 
rhythm of, 33 
Spleen, 54 
Splashing or succussion sounds, 

135, 138, 179, 267 
Stethoscope, advantages of, 76 
binaural, 76 
Allison's, 79 
Stomach, 54 

THOEACIC aneurism, 270 
diagnosis of, from em- 
pyema, 272 
Thrill, with mitral presystolic 
murmurs, 235 
with thoracic aneurism, 271 
Thymus gland, 55 
Tinkling, metallic, 135, 152, 179 
Trachea, aftections of, 27, 155 
Tracheal respiration, 82 
Tricuspid, direct murmur, 244, 
261 
lesions, diagnosis of, 261 
regurgitant murmur, 244, 

262 
safety-valve function of, 231 



Tuberculosis, acute, 161, 192 
Tubular respiration, 105 
Tumor within the chest, 26, 27, 

65, 199, 267 
Tussive signs, 152 

significance of, 153 

Tympanitic dulness, 68, 200 

resonance, 40, 48, 68 

conditions causing, 68 

VALVULAK cardiac lesions, 
219, 257 
aortic, 260 
mitral, 257 
pulmonic, 262 
tricusp»id, 261 
Venous hum, 240 
Vesicular rale, 131 

resonance, normal, 47, 48 
Vesiculo-cavernous respiration, 

115 
Vesiculo-tympanitic resonance, 
70, 165 
conditions causing, 70 
Vocal fremitus, diminished or 
suppressed, 151 
normal, 90, 92 
increased, 143, 146 
resonance, diminished and 
suppressed, 150 
normal, 89, 90 

in different regions, 
92 
increased, 142, 144 
signs of disease, 140 
Voice, abnormal, 140 
amphoric, 149 
laryngeal and tracheal, 89 
normal, 90, 92 

WAVY respiration, 120, 196 
"Whisper, amphoric, 149 
bronchial, in creased, 146 
cavernous, 147 
in different regions, 97 
laryngeal or tracheal, 95 
normal bronchial, 95 
Whispering pectoriloquy, 148 



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